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A nurse is teaching a client about ways to reduce the risk of deep vein thrombosis (DVT) after surgery. What should the nurse include in the teaching?
- A. Rest in bed for long periods
- B. Use sequential compression devices
- C. Avoid leg exercises
- D. Keep legs crossed
Correct Answer: B
Rationale: The correct answer is to 'Use sequential compression devices.' Sequential compression devices help prevent DVT by promoting venous return, reducing stasis in the veins, and preventing blood clot formation. Resting in bed for long periods (Choice A) can actually increase the risk of DVT due to decreased mobility. Avoiding leg exercises (Choice C) is also not recommended as mobilization and exercises can help prevent blood clots. Keeping legs crossed (Choice D) can impede blood flow and is not advisable in reducing the risk of DVT.
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A nurse is assessing a client who reports pain and redness at the site of a peripheral IV. What should the nurse do first?
- A. Apply a cold compress to the site
- B. Discontinue the IV line
- C. Notify the provider
- D. Increase the IV flow rate
Correct Answer: B
Rationale: When a client reports pain and redness at the site of a peripheral IV, indicating signs of phlebitis, the nurse's initial action should be to discontinue the IV line. This helps prevent further complications and ensures patient safety. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider (Choice C) is important but not the initial step. Increasing the IV flow rate (Choice D) can exacerbate the inflammation and should be avoided.
A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?
- A. Steamed carrots
- B. Mashed potatoes
- C. Orange slices
- D. Soft-cooked eggs
Correct Answer: C
Rationale: The correct answer is C: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices have membranes that can be challenging to consume for individuals with swallowing difficulties. Steamed carrots (Choice A) and mashed potatoes (Choice B) are typically suitable for a mechanical soft diet as they can be easily mashed or cut into smaller pieces. Soft-cooked eggs (Choice D) are also appropriate for this diet as they are soft and easy to chew.
A nurse is caring for a client who is postop following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased fiber intake
- B. Decreased physical activity
- C. Frequent urge suppression
- D. Adequate sleep
Correct Answer: B
Rationale: The correct answer is B: Decreased physical activity. Following abdominal surgery, reduced physical activity can contribute to constipation due to decreased bowel motility. Increased fiber intake (choice A) generally helps prevent constipation by adding bulk to the stool. Frequent urge suppression (choice C) may lead to issues like urinary retention but is not directly linked to constipation. Adequate sleep (choice D) is important for overall recovery but does not significantly impact constipation risk.
While documenting client care, which entry should the nurse identify as an example of implementing client care?
- A. Documenting the client's pain level
- B. Monitoring the client's urine output
- C. Assessing the client's range of motion
- D. Contacting the provider to report client findings
Correct Answer: D
Rationale: The correct answer is D because contacting the provider to report client findings is an example of implementing care. Implementation involves putting the care plan into action based on assessment data. While options A, B, and C are important aspects of client care, they mainly focus on assessment rather than the actual implementation of care.
A nurse is teaching a client with diabetes mellitus about foot care. What is the most important instruction the nurse should include?
- A. Apply lotion between the toes after bathing
- B. Inspect feet daily for injuries
- C. Wear shoes only indoors
- D. Cut toenails in a rounded shape
Correct Answer: B
Rationale: Inspecting feet daily for injuries is crucial for clients with diabetes to prevent unnoticed wounds from becoming infected. This instruction is the most important as it helps in early detection and management of foot problems. Choice A is incorrect because applying lotion between the toes can lead to excessive moisture, increasing the risk of fungal infections. Choice C is wrong as wearing shoes indoors can also lead to foot issues. Choice D is incorrect because cutting toenails in a rounded shape can result in ingrown toenails, posing a risk for infection.