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A healthcare professional is assessing a client who has deep-vein thrombosis (DVT). Which of the following findings should the professional expect?
- A. Swelling of the affected limb.
- B. Diminished peripheral pulses.
- C. Coolness of the affected limb.
- D. Redness and warmth of the affected limb.
Correct Answer: D
Rationale: Redness and warmth of the affected limb are classic signs of deep-vein thrombosis (DVT) due to inflammation and increased blood flow. These symptoms occur as a result of the blood clot obstructing normal blood flow and causing localized inflammation in the affected limb. Swelling of the affected limb, diminished peripheral pulses, and coolness are not typically associated with DVT. Swelling can be present but is often accompanied by the characteristic redness and warmth. Diminished pulses and coolness are more indicative of arterial insufficiency rather than venous thrombosis.
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A client has a new diagnosis of hypertension and is being taught about dietary management. Which of the following client statements indicates an understanding of the teaching?
- A. I will increase my intake of dairy products.
- B. I will eat more fresh fruits and vegetables.
- C. I will limit my intake of whole grains.
- D. I will consume more red meat.
Correct Answer: B
Rationale: The correct answer is B because increasing the intake of fresh fruits and vegetables can help manage blood pressure. These foods are rich in nutrients like potassium, fiber, and antioxidants, which are beneficial for individuals with hypertension. Dairy products are usually high in saturated fats, which can be detrimental to blood pressure control. Whole grains are generally recommended for their health benefits, including maintaining a healthy weight and heart health. Red meat is often high in saturated fats and can contribute to high blood pressure and other cardiovascular risks.
A client with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?
- A. Encourage pursed-lip breathing.
- B. Administer oxygen at 6 L/min via nasal cannula.
- C. Place the client in a supine position.
- D. Restrict fluid intake to less than 1,500 mL/day.
Correct Answer: A
Rationale: Encouraging pursed-lip breathing is essential for clients with COPD as it aids in improving ventilation and gas exchange. This technique helps keep the airways open longer during exhalation, preventing air trapping and promoting more effective breathing. Administering oxygen, placing the client in a supine position, or restricting fluid intake are not primary interventions for managing COPD and may not address the specific respiratory needs of the client.
When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?
- A. Massage the reddened area.
- B. Apply a donut-shaped cushion.
- C. Reposition the client every 3 hours.
- D. Use a transparent film dressing.
Correct Answer: D
Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.
A client with a seizure disorder is under the care of a nurse. Which of the following precautions should the nurse include in the plan?
- A. Place a padded tongue depressor at the bedside.
- B. Keep the bed in the lowest position.
- C. Restrain the client during a seizure.
- D. Keep the lights dim in the client's room.
Correct Answer: B
Rationale: Keeping the bed in the lowest position is crucial for ensuring the safety of the client during a seizure. Lowering the bed reduces the risk of injury if the client falls during a seizure episode. It is important not to restrain the client during a seizure as it can lead to further injury. Placing a padded tongue depressor at the bedside is not appropriate and can pose a risk of injury if used incorrectly. Keeping the lights dim in the client's room is not directly related to safety during a seizure and is not a standard precaution.
What action is required by law when preparing to administer a controlled substance?
- A. Verify the client's identification using two identifiers.
- B. Document the medication administration in the client's chart immediately.
- C. Return any unused portion of the medication to the pharmacy.
- D. Have a second nurse witness the disposal of any unused portion.
Correct Answer: D
Rationale: Having a second nurse witness the disposal of any unused portion of a controlled substance is a legal requirement to ensure proper disposal, prevent diversion, and maintain accountability. This practice helps in reducing the risk of misuse or unauthorized access to controlled substances, enhancing patient safety, and complying with legal regulations and standards.