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A nurse is caring for a client who is 3 hours postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the foot.
- B. Keep the client's knees in a flexed position while they lie in bed.
- C. Massage the client's legs every 4 hours while they are awake.
- D. Limit the client's fluid intake to 2,000 mL daily.
Correct Answer: A
Rationale: Correct Answer: A. Encourage the client to perform circumduction of the foot.
Rationale:
1. Circumduction of the foot promotes blood flow in the lower extremity, preventing stasis and reducing the risk of venous thromboembolism.
2. This action helps in maintaining muscle tone and preventing blood clots in the postoperative period.
3. Encouraging mobility also prevents complications like deep vein thrombosis.
Summary of Incorrect Choices:
B. Keeping the client's knees in a flexed position may restrict blood flow and increase the risk of thromboembolism.
C. Massaging the client's legs can dislodge blood clots and lead to embolism.
D. Limiting fluid intake can increase the risk of dehydration and thickening of blood, which can contribute to thrombus formation.
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A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Which of the following findings require immediate follow-up?
- A. Temperature 37.1° C (98.8° F)
- B. Heart rate 110/min and irregular
- C. Respiratory rate 24/min
- D. Blood pressure 164/80 mm Hg
Correct Answer: B
Rationale: The correct answer is B: Heart rate 110/min and irregular. This finding indicates potential cardiac issues like myocardial infarction. Immediate follow-up is necessary to assess for any life-threatening conditions. The other options are not as urgent. A: Temperature within normal range, C: Respiratory rate slightly elevated but not critical, D: Elevated blood pressure but not as concerning as irregular heart rate.
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the best option because it ensures effective communication between the nurse and the client. By having a professional interpreter present, the nurse can accurately gather information, provide instructions, and address any concerns the client may have. Asking a family member to be present (A) may not guarantee accurate communication. Familiarizing with sign language (C) may not be sufficient for complex medical discussions. Using a board with pictures (D) may not be effective for detailed conversations.
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
- A. These discomforts should decrease with time.'
- B. You should avoid intercourse to prevent injury to your vagina.'
- C. Women your age experience thickening of the vaginal tissue.'
- D. Your symptoms are likely due to decreasing estrogen levels.'
Correct Answer: D
Rationale: The correct answer is D: "Your symptoms are likely due to decreasing estrogen levels." This response is correct because vaginal dryness and itching are common symptoms of vaginal atrophy, which is often caused by decreased estrogen levels in older adult women. The nurse's acknowledgment and explanation of this physiological change can help the client understand the root cause of her symptoms and guide further discussion on appropriate treatment options, such as hormone therapy or vaginal moisturizers.
Choice A is incorrect because it dismisses the client's discomfort without addressing the underlying cause. Choice B is incorrect as it provides potentially harmful advice without addressing the issue. Choice C is incorrect as it inaccurately describes the condition of vaginal tissue in older women.
A nurse is providing discharge teaching to a client who had a bilateral orchiectomy. The nurse should instruct the client to expect which of the following symptoms?
- A. Hypoglycemia
- B. Increased libido
- C. Hot flashes
- D. Increased muscle mass
Correct Answer: C
Rationale: The correct answer is C: Hot flashes. After a bilateral orchiectomy (removal of both testicles), there is a sudden decrease in testosterone levels, leading to hormonal imbalances. This can result in hot flashes, which are commonly experienced by men undergoing androgen deprivation therapy. Hypoglycemia (A) is not typically associated with orchiectomy. Increased libido (B) and increased muscle mass (D) are actually expected to decrease due to the decrease in testosterone levels post-orchiectomy.
A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?
- A. Palpable thrill
- B. Memorantake blood pressure
- C. Absence of a bruit
- D. Dilated appearance of the graft
Correct Answer: A
Rationale: The correct answer is A: Palpable thrill. A palpable thrill indicates that there is adequate circulation of the arteriovenous graft. A thrill is a vibration felt over the graft site, which suggests that blood is flowing through the graft properly. A palpable thrill is a positive sign of good circulation.
The other choices are incorrect because:
B: Membranous blood pressure does not provide information about the circulation of the graft.
C: Absence of a bruit could indicate decreased or absent blood flow through the graft.
D: Dilated appearance of the graft does not necessarily indicate adequate circulation; it could be due to other reasons such as infection or inflammation.