Nokea
A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?
- A. Position the client with the affected extremity higher than the heart
- B. Administration of acetaminophen
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct Answer: D
Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.
You may also like to solve these questions
When managing blood pressure at home, which statement by the client indicates an understanding of the teaching provided by a nurse for hypertension?
- A. I will take my medication only when I feel dizzy.
- B. I will check my blood pressure at least once a week.
- C. I will stop taking my medication once my blood pressure is within normal range.
- D. I will sit quietly for 5 minutes before measuring my blood pressure.
Correct Answer: D
Rationale: The correct answer is D because sitting quietly for 5 minutes before measuring blood pressure ensures an accurate reading and helps monitor hypertension. Choice A is incorrect as medications for hypertension should be taken as prescribed, not based on symptoms like dizziness. Choice B is not ideal as blood pressure should be checked more frequently, preferably daily. Choice C is incorrect as stopping medication abruptly once blood pressure is normal can lead to rebound hypertension.
A client with gastroesophageal reflux disease (GERD) is receiving teaching from a nurse. Which of the following instructions should the nurse include?
- A. Lie down after meals to reduce discomfort.
- B. Limit fluid intake to 1 liter per day.
- C. Avoid eating spicy foods.
- D. Eat three large meals each day.
Correct Answer: C
Rationale: The correct answer is C: 'Avoid eating spicy foods.' Spicy foods can exacerbate symptoms of GERD by irritating the esophagus and causing discomfort. It is important for clients with GERD to avoid spicy foods to help manage their condition. Choices A, B, and D are incorrect. A client with GERD should not lie down after meals as this can worsen symptoms, limiting fluid intake to only 1 liter per day may not be appropriate for everyone, and eating three large meals each day can put pressure on the stomach and worsen GERD symptoms.
A client with preeclampsia and postpartum hemorrhage is being cared for by a nurse. The nurse should recognize that which of the following medications is contraindicated?
- A. Methylergonovine
- B. Misoprostol
- C. Dinoprostone
- D. Oxytocin
Correct Answer: A
Rationale: The correct answer is A, Methylergonovine. Methylergonovine is contraindicated in clients with preeclampsia due to the risk of hypertension. Misoprostol (choice B), Dinoprostone (choice C), and Oxytocin (choice D) are appropriate medications for managing postpartum hemorrhage and are not contraindicated in clients with preeclampsia.
What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?
- A. Apply hydrocolloid dressing
- B. Provide wound debridement
- C. Change the dressing daily
- D. Elevate the affected area
Correct Answer: A
Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.
How should a healthcare provider respond to a patient refusing treatment for religious reasons?
- A. Respect the patient's beliefs
- B. Attempt to persuade the patient
- C. Provide education on treatment benefits
- D. Document the refusal and notify the provider
Correct Answer: A
Rationale: Respecting the patient's beliefs is crucial in providing patient-centered care. Attempting to persuade the patient may violate their autonomy and decision-making capacity, leading to a breakdown in trust. Providing education on treatment benefits may be appropriate in other situations but is not the best approach when a patient refuses treatment based on religious reasons. Documenting the refusal and notifying the provider are important steps to ensure proper continuity of care, but the primary response should be to respect the patient's beliefs to maintain a trusting relationship and uphold ethical standards.