Nokea
A female client is admitted to the hospital with obesity and deep vein thrombophlebitis (DVT) of the right leg. She weighs 275 pounds. Which of the following factors is least related to her diagnosis?
- A. She has been taking oral estrogens for the last three years.
- B. She smokes two packs of cigarettes daily.
- C. Her right femur was fractured recently.
- D. She is 30 years old.
Correct Answer: D
Rationale: Age (30 years) is the least related to DVT risk compared to estrogen use, smoking, and recent fracture, which are known risk factors for thrombosis.
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The nurse identifies the concept of tissue perfusion as a client problem. Which is an antecedent of tissue perfusion?
- A. The client has a history of coronary artery disease (CAD).
- B. The client has a history of diabetes insipidus (DI).
- C. The client has a history of chronic obstructive pulmonary disease (COPD).
- D. The client has a history of multiple fractures from a motor-vehicle accident.
Correct Answer: A
Rationale: CAD (A) directly impairs cardiac perfusion due to atherosclerosis, an antecedent to perfusion issues. DI (B), COPD (C), and fractures (D) are less directly related.
Which modification used by the nurse is most appropriate when taking the blood pressure of a client who weighs 250 pounds?
- A. The nurse takes the blood pressure on the client's thigh.
- B. The nurse has the client lie down during the assessment.
- C. The nurse pumps the manometer up to 250 mm Hg.
- D. The nurse uses an extra-large blood pressure cuff.
Correct Answer: D
Rationale: An extra-large blood pressure cuff is appropriate for clients with larger arm circumferences, such as those who are obese, to ensure accurate readings. Using the thigh, lying down, or over-inflating the cuff does not address the need for proper cuff size.
The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented?
- A. Administer a thrombolytic medication.
- B. Assess the client's cardiovascular status.
- C. Prepare for insertion of a pacemaker.
- D. Obtain a permit for synchronized cardioversion.
Correct Answer: C
Rationale: Symptomatic bradycardia (syncope, hypotension) often requires a pacemaker (C). Thrombolytics (A) are for MI, assessment (B) is ongoing, and cardioversion (D) is for tachydysrhythmias.
The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include?
- A. Instruct the client to take a cough suppressant if a cough develops.
- B. Teach the client how to prevent orthostatic hypotension.
- C. Encourage the client to eat bananas to increase potassium level.
- D. Explain the importance of taking the medication with food.
Correct Answer: B
Rationale: ACE inhibitors cause hypotension, so teaching prevention of orthostatic hypotension (B) is critical. Cough suppressants (A) are inappropriate for ACE inhibitor cough, bananas (C) are unnecessary unless hypokalemia exists, and food (D) is not required.
The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement?
- A. Restrict the client's fluids as ordered.
- B. Keep the client in the supine position.
- C. Maintain oxygen saturation at 90%.
- D. Monitor the total parenteral nutrition.
Correct Answer: A
Rationale: Fluid restriction (A) prevents overload post-mitral valve surgery. Supine position (B) increases preload, SpO2 90% (C) is too low, and TPN (D) is not routine.