Nokea
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Calf swelling
- B. Bradycardia
- C. Tortuous veins
- D. Clammy skin
Correct Answer: A
Rationale: Calf swelling is a key sign of deep-vein thrombosis, requiring immediate reporting for intervention.
You may also like to solve these questions
A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Oral temperature elevated at 0800.
- B. Episiotomy approximated, 3 cm (1.18 in) in length.
- C. Client instructed on self-care needs.
- D. Client drank adequate amounts of fluid with meals.
Correct Answer: B
Rationale: Specific documentation like episiotomy status provides measurable, objective data.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Determine the client's ability to use a communication board.
- C. Speak with a loud voice while providing the information.
- D. Avoid the use of facial gestures during the instructions.
Correct Answer: B
Rationale: A communication board aids clients with expressive aphasia in responding, enhancing understanding.
A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Conduct staff communications away from the client's room.
- B. Turn off alarms on bedside monitoring equipment.
- C. Avoid entering the client's room unless requested during the night.
- D. Turn on the client's TV to distract from hallway noise.
Correct Answer: A
Rationale: Reducing noise by moving staff communication away enhances sleep without compromising safety.
A nurse is reinforcing a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?
- A. Keep legs straight.
- B. Bend at the waist.
- C. Tighten the abdominal muscles.
- D. Hold object away from the body.
Correct Answer: C
Rationale: Tightening abdominal muscles stabilizes the spine, reducing back injury risk during lifting.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
- B. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- C. Unnecessary sterile items are placed on the field.
- D. The sterile solution is poured with the bottle held over the field.
Correct Answer: D
Rationale: Pouring with the bottle over the field risks contamination from the non-sterile bottle.