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.
You may also like to solve these questions
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 nurse is transcribing the doctor’s orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement?
- A. Discuss the order with the health-care provider.
- B. Take the client’s apical pulse rate before administering.
- C. Check the client’s potassium level before giving the medication.
- D. Determine if a digoxin level has been drawn.
Correct Answer: A
Rationale: Lanoxin (digoxin) 2.5 mg (A) exceeds the safe dose (0.125–0.25 mg daily), requiring HCP clarification. Pulse (B), potassium (C), and digoxin level (D) are routine but secondary to dose error.
When two rescuers perform CPR on an adult, what is the ratio of compressions to ventilations?
- A. 30 compressions to 2 breaths
- B. 10 compressions to 1 breath
- C. 1 compression for each breath
- D. 1 compression to 5 breaths
Correct Answer: A
Rationale: Two-rescuer adult CPR uses a 30:2 ratio to balance circulation and oxygenation.
Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)?
- A. Creatine kinase (CK-MB).
- B. Lactate dehydrogenase (LDH).
- C. Troponin.
- D. White blood cells (WBCs).
Correct Answer: C
Rationale: Troponin (C) rises within 3–4 hours post-MI, making it the earliest marker. CK-MB (A) rises in 4–6 hours, LDH (B) in 24–48 hours, and WBCs (D) are nonspecific.
An adult client is admitted with a diagnosis of left-sided congestive heart failure. Which assessment finding would most likely be present?
- A. Distended neck veins
- B. Dyspnea
- C. Hepatomegaly
- D. Pitting edema
Correct Answer: B
Rationale: Dyspnea is a hallmark symptom of left-sided congestive heart failure due to pulmonary congestion. Distended neck veins, hepatomegaly, and pitting edema are more associated with right-sided heart failure.