Nokea
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A nurse is caring for a client who has deep-vein thrombosis. Which of the following interventions should the nurse plan to take?
- A. Place the client's bed in reverse Trendelenburg position.
- B. Massage the affected extremity every 4 hr.
- C. Apply cold compresses to the affected extremity.
- D. Measure the calf of the affected extremity each shift.
- E. Elevate the leg.
- F. Apply warm compresses.
- G. Administer heparin.
Correct Answer: D
Rationale: Measuring the calf monitors for swelling (worsening DVT); massage and cold can dislodge clots, and reverse Trendelenburg isn't specific.
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A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Administer an antiemetic after each meal.
- C. Season foods with spices.
- D. Provide a high-calorie diet.
Correct Answer: D
Rationale: A high-calorie diet addresses malnutrition in AIDS by meeting increased metabolic needs. Large meals may be overwhelming, antiemetics are given before meals if needed, and spices may not be tolerated.
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
- A. WBC count 9,000/mm³ (5,000 to 10,000/mm³)
- B. Temperature 37.3° C (99.1° F)
- C. Changed mental status
- D. Diminished reflexes
Correct Answer: C
Rationale: Older adults with bladder infections (UTIs) often lack classic symptoms, presenting with altered mental status confusion or lethargy from systemic inflammation or bacteremia, per geriatric care standards. Normal WBC (9,000/mm³) doesn't rule out UTI; leukocytosis isn't always present early. A slight fever (37.3°C) supports infection but isn't definitive alone. Diminished reflexes tie to aging or neurology, not UTI. Mental status change is a red flag prompting urinalysis and antibiotics preventing sepsis, making it the strongest indicator in this population.
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?
- A. Abdominal wound dry, without redness
- B. Client received an adequate amount of fluid
- C. Client status unchanged throughout shift
- D. Incision healing well
- E. Pain level stable
- F. No fever noted
- G. Ambulated without difficulty
Correct Answer: A
Rationale: Specific, objective data like 'dry, without redness' is required; vague terms like 'adequate' or 'unchanged' are insufficient.
A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will use a skin sealant before I apply the bag.
- B. I will use moisturizing soap to clean around the stoma before applying the bag.
- C. I will cut the wafer opening one-fourth of an inch larger than the stoma
- D. I will need to empty the bag every 4 to 6 hours.
Correct Answer: A
Rationale: Using a skin sealant protects the peristomal skin, showing understanding of ileostomy care. Moisturizers can interfere, the wafer should be 1/8 inch larger, and emptying frequency varies but isn't the best indicator here.
A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. Which of the following changes should the nurse identify as the priority finding?
- A. Heart rate change from 110/min to 68/min
- B. Respiratory rate change from 12/min to 20/min
- C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg
- D. Temperature change from 36.6°C (97.9°F) to 38.8°C (101.9°F)
Correct Answer: C
Rationale: Blood pressure dropping to 86/50 mm Hg from 118/78 signals hypotension, risking organ perfusion a circulation priority per ABCs. Heart rate falling to 68 from 110 may normalize post-tachycardia, less urgent without distress. Respiratory rate rising to 20 from 12 suggests compensation, but hypotension trumps breathing acuity. Fever at 38.8°C indicates infection, but hemodynamic instability is more immediate shock or bleeding needs rapid action. This finding drives urgent assessment (e.g., fluids, vasopressors), aligning with triage protocols, making it the nurse's top concern.