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. Clammy skin
- B. Tortuous veins
- C. Bradycardia
- D. Calf swelling
Correct Answer: D
Rationale: Calf swelling is a key sign of DVT, indicating possible venous obstruction needing urgent evaluation.
You may also like to solve these questions
A nurse is performing a wound irrigation for a client who has methicillin-resistant Staphylococcus aureus. When removing personal protective equipment, which of the following pieces should the nurse remove first?
- A. Gloves
- B. Gown
- C. Goggles
- D. Mask
Correct Answer: A
Rationale: Removing gloves first prevents hand contamination when removing other PPE.
A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
- A. Respiratory therapist
- B. Speech-language pathologist
- C. Registered dietitian
- D. Occupational therapist
Correct Answer: B
Rationale: Speech-language pathologists specialize in dysphagia, assessing and treating swallowing issues post-stroke.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Dry the wound bed with gauze squares.
- C. Cleanse the wound with cotton balls.
- D. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
Correct Answer: A
Rationale: A 10-mL syringe provides adequate pressure for effective, safe wound irrigation.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I love to eat apples and black-eyed peas.
- B. I drink an average of 2,000 milliliters of water daily.
- C. I take a prescribed opioid pain medication at bedtime.
- D. I drink two hot cups of coffee each morning.
Correct Answer: C
Rationale: Opioids slow bowel motility, increasing constipation risk, unlike fiber-rich foods or hydration.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 25 kg × 50 mg/kg/day = 1250 mg/day; 1250 mg ÷ 4 = 312.5 mg/dose; 312.5 mg ÷ (125 mg/5 mL) = 12.5 mL.