Nokea
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)
- A. Client who had a reaction to contrast dye yesterday
- B. Client with a new spinal cord injury on a rotating bed
- C. Middle-aged man with an exacerbation of asthma
- D. Older client who is 1-day post hip replacement surgery
- E. Young obese client with a fractured femur
Correct Answer: B,D,E
Rationale: Risk factors for PE include prolonged immobility (spinal cord injury, post-hip surgery), obesity, and trauma (fractured femur). Contrast dye reaction and asthma are not associated with increased PE risk.
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A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best?
- A. It will increase the motility of the gastrointestinal tract
- B. It will keep the gastrointestinal tract functioning normally
- C. It will prepare the gastrointestinal tract for enteral feedings
- D. It will prevent ulcers from the stress of mechanical ventilation
Correct Answer: D
Rationale: Ranitidine, a histamine blocker, is used prophylactically to prevent stress ulcers, which are common in mechanically ventilated clients due to physiological stress.
When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
- A. Avoid drinking alcohol
- B. Eat more omega-3 fatty acids
- C. Exercise on a regular basis
- D. Maintain a healthy weight
- E. Stop smoking cigarettes
Correct Answer: C,D,E
Rationale: Hormonal birth control increases clotting risk. Health promotion measures to reduce PE risk include regular exercise, maintaining a healthy weight, and smoking cessation, as these address immobility, obesity, and smoking-related risks.
A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg. What action by the nurse is best?
- A. Administer oxygen at 2 L/min via nasal cannula
- B. Obtain a STAT chest X-ray
- C. Prepare to administer thrombolytic therapy
- D. Monitor the client's blood pressure every 15 minutes
Correct Answer: C
Rationale: The client's symptoms of anxiety, shortness of breath, chest pain, and hypotension suggest a pulmonary embolism, which can significantly impair gas exchange. Thrombolytic therapy is indicated for a large pulmonary embolism causing hemodynamic instability, as it can dissolve the clot and restore oxygenation.
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)
- A. Allow visitors at the client's bedside
- B. Ensure the client can communicate if awake
- C. Keep the television tuned to a favorite channel
- D. Provide back and hand massages when turning
- E. Turn the client every 2 hours or more
Correct Answer: A,B,D,E
Rationale: Comfort measures for ventilated clients include allowing visitors, enabling communication (e.g., via writing boards), providing massages during turning, and frequent repositioning to prevent pressure injuries. Keeping the TV on may disrupt rest.
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
- A. Assess the cause of the agitation
- B. Reassure the client that he or she is safe
- C. Restrain the client's hands
- D. Sedate the client immediately
Correct Answer: A
Rationale: Determining the cause of agitation (e.g., pain, hypoxia, or anxiety) is the first step to address the underlying issue. Restraints or sedation may be needed but are not the initial action.