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A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?
- A. Obtain a venous duplex ultrasound.
- B. Obtain impedance plethysmography.
- C. Monitor Homan's sign
- D. Apply cold therapy to the affected leg
Correct Answer: A
Rationale: Symptoms suggest deep vein thrombosis (DVT), and a venous duplex ultrasound is the standard diagnostic test to confirm a thrombus. Other options are less reliable or inappropriate.
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A nurse is teaching a group of clients about causes for developing hearing loss, which of the following risk factors should the nurse include in the teaching?
- A. Alcohol use disorder
- B. Prolonged exposure to loud noises
- C. Exposure to environmental toxins
- D. Contact with excessive heat
Correct Answer: B
Rationale: Prolonged exposure to loud noises causes noise-induced hearing loss. Environmental toxins can also contribute, but noise exposure is the most direct and common risk factor.
A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?
- A. Lie on your back when sleeping.
- B. Wash your hair 24 hr after surgery.
- C. Resume your exercise routine.
- D. Eat foods that are soft
Correct Answer: D
Rationale: Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging packing or stitches, and promote comfort during initial healing. Lying on the back is not necessarily required unless specified by the surgeon. Hair washing within 24-48 hours post-surgery risks infection. Exercise is typically restricted initially to prevent strain on the surgical area.
A nurse is caring for a client who has developed pulmonary embolism (PE). Which of the following diagnostic tests should the nurse anticipate the provider to prescribe to confirm the client's condition?(Select All that Apply.)
- A. D-dimer blood test
- B. Complete blood count (CBC)
- C. CT scan
- D. Chest x-ray
- E. Lung ventilation and perfusion scan (VQ scan)
Correct Answer: A,C,E
Rationale: A D-dimer test measures clot breakdown products in the blood, with elevated levels suggesting the presence of an abnormal blood clot like in PE. A CT pulmonary angiography is the gold standard for diagnosing PE, providing detailed images of the lung's blood vessels. A VQ scan is another diagnostic tool for PE, especially for clients who cannot tolerate contrast dye, as it identifies ventilation-perfusion mismatches suggestive of PE. A CBC is not typically used to diagnose PE, and a chest x-ray is performed to rule out other causes but does not confirm PE.
A nurse is caring for a client who has sickle cell anemia. The client asks, 'Why do I feel so tired and fatigued all of the time?' Which of the following information should the nurse provide?
- A. You have had a gastrointestinal bleed.
- B. You have a low ferritin level.
- C. You have an autoimmune disease.
- D. You have fewer red blood cells.
Correct Answer: D
Rationale: Sickle cell anemia causes fewer healthy red blood cells due to fragile sickled cells, leading to anemia and reduced oxygen delivery, causing fatigue.
A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
- A. 2 hr after obtaining blood from the blood bank
- B. When the client states he is ready to start the infusion
- C. As soon as the nurse can prepare the client and the administration set
- D. when the client has finished eating lunch
Correct Answer: C
Rationale: Blood products should be infused as soon as possible after preparation, ideally within 30 minutes, to reduce bacterial contamination risk and ensure efficacy.