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A nurse is caring for a client who is 12 hr postpartum and has deep vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?
- A. Apply an ice pack to the affected extremity for 20 min every 2 hr.
- B. Administer aspirin for pain.
- C. Massage the affected extremity every 4 hr.
- D. Initiate bed rest.
Correct Answer: D
Rationale: Bed rest prevents clot dislodgement, reducing pulmonary embolism risk. Ice, aspirin, or massage could increase bleeding or dislodge the clot, worsening the condition.
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A nurse is reinforcing teaching with a client who has a new prescription for bupropion. Which of the following statements should the nurse include?
- A. Take this medication at bedtime.
- B. You might have dry mouth while taking this medication.
- C. You need to avoid tyramine-rich foods.
- D. You can expect immediate mood improvement.
Correct Answer: B
Rationale: Bupropion can cause dry mouth, a side effect to monitor. It's taken in the morning, tyramine isn't a concern, and mood improvement takes weeks.
A nurse is caring for a client who is receiving IV vancomycin. Which of the following actions should the nurse take?
- A. Infuse the medication over 30 min.
- B. Monitor the client for tinnitus.
- C. Administer the medication with an antihistamine.
- D. Check the client's blood pressure every 4 hr.
Correct Answer: B
Rationale: Vancomycin can cause ototoxicity, so monitoring for tinnitus is essential. It's infused over 60-90 minutes, antihistamines aren't needed, and blood pressure checks aren't specific to vancomycin.
A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Encourage the client to flex the knee every 2 hr.
- B. Apply a continuous passive motion machine as prescribed.
- C. Instruct the client to keep the leg in a dependent position.
- D. Administer a diuretic to reduce swelling.
Correct Answer: B
Rationale: A CPM machine promotes mobility and prevents stiffness as prescribed. Flexion timing varies, dependent positioning increases swelling, and diuretics aren't routine.
A nurse is caring for a client who is receiving IV gentamicin. Which of the following findings should the nurse report to the provider?
- A. The client reports mild nausea.
- B. The client's urine output is 30 mL/hr.
- C. The client's hearing has decreased.
- D. The client's blood pressure is 120/78 mm Hg.
Correct Answer: C
Rationale: Decreased hearing suggests ototoxicity, a serious gentamicin side effect requiring reporting. Nausea, low urine output, and normal BP are less urgent.
A nurse is caring for a client who is postoperative following a cesarean birth. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate within 24 hr.
- B. Instruct the client to avoid coughing.
- C. Apply a cold pack to the incision site.
- D. Administer a laxative every 2 hr.
Correct Answer: A
Rationale: Ambulation within 24 hours prevents thromboembolism and aids recovery. Coughing supports lung function, cold packs aren't standard, and laxatives aren't given that frequently.