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The client is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy.
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. Massage the affected extremity every 4 hr.
- B. Initiate bed rest.
- C. Apply an ice pack to the affected extremity for 20 min every 2 hr.
- D. Administer aspirin for pain.
Correct Answer: B
Rationale: Bed rest prevents dislodging the clot while on anticoagulants.
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A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will wipe away yellow crusts that form around the incision.
- B. I will make sure that my baby's diaper is applied snugly.
- C. I will apply pressure with gauze if I see bleeding.
- D. I will apply antibiotic ointment to my baby's penis.
Correct Answer: C
Rationale: Applying pressure with gauze controls bleeding, a key aspect of Plastibell circumcision care.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
- A. Family medical history
- B. Medications taken prior to admission
- C. Physical assessment findings
- D. Medical health insurance claim
Correct Answer: C
Rationale: Physical assessment findings inform the therapist's treatment plan.
A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?
- A. Place the client in a sitting position.
- B. Tie the restraint to the railing of the client's bed.
- C. Ensure the restraint is placed across the client's chest.
- D. Apply the restraint under the client's clothes.
Correct Answer: A
Rationale: Placing the client in a sitting position ensures safety and proper restraint application.
A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?
- A. Believes that his brother's death will be reversible
- B. Alienates himself from his peers
- C. Believes his bad behavior is causing his brother's death
- D. Regresses to an earlier developmental level
Correct Answer: A
Rationale: School-age children often see death as reversible, like sleep.
The client has heart failure and is taking furosemide.
A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?
- A. Increased urinary output
- B. Decreased hemoglobin level
- C. Increased weight of 0.91 kg (2 lb)
- D. Decreased BUN level
Correct Answer: A
Rationale: Increased urinary output reflects furosemide's diuretic effect, reducing fluid overload.