Nokea
A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. All of these may indicate which of the following medical conditions?
- A. Patient may have a DVT.
- B. Patient may be exhibiting signs of dermatitis.
- C. Patient may be in the late phases of CHF.
- D. Patient may be experiencing anxiety after surgery.
Correct Answer: A
Rationale: All of these factors (SOB, calf pain, and warmth) indicate a deep vein thrombosis (DVT), which can be a postoperative complication.
You may also like to solve these questions
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
- A. Administer O2.
- B. Turn the client on her left side.
- C. Notify the physician.
- D. No action is necessary.
Correct Answer: D
Rationale: It is an early deceleration as a result of head compression, and at this time no action is necessary. Close observation of the mother and baby is needed.
The LPN is teaching a first-time mother about breastfeeding her newborn. Which statement, if made by the mother, would reflect that the teaching had been successful?
- A. My baby should be having at least 4-6 wet diapers a day until 1 month.
- B. It's nice that breastfed babies eat a bit less than formula fed babies.
- C. My baby should be nursing 8-12 times a day during this period.
- D. I'm a little nervous about my milk coming in tomorrow. I've heard it's uncomfortable.
Correct Answer: C
Rationale: Newborns should be nursing 8-12 times during the newborn period. Until a mother's milk comes in, babies typically have a wet diaper count that corresponds to the number of days since their birth (one wet diaper for a 1-day-old baby, and so on). Once they are getting milk and not colostrum, infants should have 4-6 wet diapers a day. A mother's milk usually comes in 3-4 days after the initial colostrum stage. Breast milk is digested faster than formula, so breastfed babies typically eat more frequently.
The client using latanoprost eye drops for treatment of glaucoma calls the ophthalmology clinic after noting a brown pigmentation of the iris. Which nursing action is most appropriate?
- A. Instruct the client to come to the clinic to have the eyes and medication evaluated.
- B. Schedule an appointment for the client to see an internist for liver function studies.
- C. Tell the client that the pigmentation is from the latanoprost but will eventually regress.
- D. Recommend that the client wear sunglasses when outdoors to decrease iris pigmentation.
Correct Answer: A
Rationale: A: A side effect of latanoprost (Xalatan), a prostaglandin, includes a heightened brown pigmentation of the iris, which stops progressing when latanoprost is discontinued. B: Jaundiced sclera, and not brown iris pigmentation, would suggest the need to evaluate liver function. C: The brown iris pigmentation from the latanoprost does not usually regress. D: Wearing sunglasses will have no effect on the iris pigmentation.
The nurse is assessing the laboratory test results for the male client receiving testosterone replacement therapy for treatment of hypogonadism. Which laboratory test result is most important for the nurse to review?
- A. Fasting lipid profile
- B. Partial thromboplastin time
- C. Urinalysis
- D. Serum potassium
Correct Answer: A
Rationale: A: The most important test is the fasting lipid profile because testosterone can lower plasma levels of HDLs and elevate plasma levels of LDLs, increasing the risk of atherosclerosis. B: Testosterone has little effect on PTT. C: Testosterone has little effect on urine. D: Testosterone has little effect on serum potassium.
The adolescent, who is receiving morphine sulfate via PCA, has itching. Which medication listed on the client's MAR should the nurse plan to administer to relieve the itching?
- A. Diazepam
- B. Diphenhydramine
- C. Naloxone hydrochloride
- D. Butenafine hydrochloride
Correct Answer: B
Rationale: A: Diazepam (Valium) acts on the CNS to produce sedation, hypnosis, skeletal muscle relaxation, and anticonvulsant activity. B: Diphenhydramine (Benadryl) is an antihistamine that blocks histamine release by competing for the histamine receptors. C: Naloxone (Narcan) is a narcotic antagonist that reverses the effects of opiates. D: Butenafine (Mentax) is an antifungal antibiotic used to treat tinea pedis, tinea corporis, and tinea cruris.