Nokea
A nurse is caring for a postoperative client. Which procedure places the client at highest risk for DVT?
- A. Appendectomy
- B. Hip arthroplasty
- C. Cholecystectomy
- D. Tonsillectomy
Correct Answer: B
Rationale: The correct answer is B: Hip arthroplasty. This procedure involves prolonged immobility, causing blood stasis and increasing the risk of deep vein thrombosis (DVT). The reduced blood flow in the legs can lead to clot formation. Appendectomy (A), cholecystectomy (C), and tonsillectomy (D) are not typically associated with prolonged immobility like hip arthroplasty, thus lower DVT risk.
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A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
- A. Bleeding from the gums
- B. Chest pain
- C. Fatigue
- D. Severe headache
Correct Answer: A
Rationale: The correct answer is A: Bleeding from the gums. Myelosuppression leads to decreased production of blood cells, including platelets, which are essential for clotting. Bleeding from the gums is a common sign of thrombocytopenia, a condition where there are low platelet levels. Chest pain, fatigue, and severe headache are not directly associated with myelosuppression. Monitoring for bleeding tendencies is crucial in clients with myelosuppression to prevent complications like hemorrhage.
A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history?
- A. History of breast cancer
- B. History of hypertension
- C. History of diabetes
- D. History of osteoarthritis
Correct Answer: A
Rationale: The correct answer is A: History of breast cancer. Menopausal hormone therapy (HT) is contraindicated in women with a history of breast cancer due to the potential risk of hormone-dependent cancer recurrence. Hormones can stimulate the growth of estrogen-sensitive breast cancer cells, increasing the risk of cancer recurrence. Therefore, it is crucial for the nurse to inform the client with a history of breast cancer that HT is not recommended. Choices B, C, and D are not directly contraindications for HT in menopausal clients, as long as these conditions are well-controlled and monitored.
A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?
- A. Give the ordered KCL as prescribed.
- B. Hold the KCL and notify the healthcare provider.
- C. Administer potassium via IV push.
- D. Check the client's potassium level again in 1 hour.
Correct Answer: A
Rationale: The correct answer is A: Give the ordered KCL as prescribed. The nurse should administer potassium chloride as prescribed because the client's potassium level of 3.2 mEq/L is within the normal range (3.5-5.0 mEq/L). Potassium chloride is indicated for clients with hypokalemia (low potassium levels), and the client's level falls within the normal range, so administering the ordered KCL is appropriate. Holding the KCL is unnecessary since the potassium level is not critically low. Administering potassium via IV push is not indicated as the client's potassium level is not critically low. Checking the client's potassium level again in 1 hour is unnecessary as the level is already within the normal range.
A nurse is teaching a middle-aged client about hypertension. Which of the following information should the nurse include in the teaching?
- A. Calcium channel blockers are the first choice for hypertension.
- B. Beta-blockers are the first type of medication for hypertension.
- C. ACE inhibitors are the first choice for hypertension.
- D. Diuretics are the first type of medication to control hypertension.
Correct Answer: A
Rationale: Diuretics are the first-line treatment for hypertension as they reduce blood volume, lowering blood pressure.
A nurse is planning care for a client with a T4 spinal cord injury at risk for UTIs. What should be included?
- A. Limit fluid intake.
- B. Encourage fluid intake at and between meals.
- C. Restrict intake of acidic foods.
- D. Use an indwelling catheter continuously.
Correct Answer: B
Rationale: The correct answer is B: Encourage fluid intake at and between meals. This is because increasing fluid intake helps to flush out bacteria from the urinary tract, reducing the risk of UTIs. Limiting fluid intake (choice A) can lead to concentrated urine, making it easier for bacteria to multiply. Restricting acidic foods (choice C) does not directly impact the risk of UTIs. Using an indwelling catheter continuously (choice D) actually increases the risk of UTIs due to the constant presence of a foreign body in the urinary tract. Encouraging fluid intake at and between meals is the most effective way to prevent UTIs in clients with spinal cord injuries.