Nokea
A patient is diagnosed with deep vein thrombosis (DVT). Which of the following actions should the nurse take?
- A. Massage the affected extremity every 2 hours.
- B. Encourage the patient to ambulate as soon as possible.
- C. Apply warm compresses to the affected extremity.
- D. Elevate the affected extremity.
Correct Answer: D
Rationale: Elevating the affected extremity is crucial in managing deep vein thrombosis (DVT) as it helps reduce swelling and promotes venous return, thereby preventing further complications such as pulmonary embolism. Massaging the affected extremity can dislodge a clot and lead to serious consequences. While ambulation is important, in DVT, early ambulation without elevation can potentially dislodge the clot. Warm compresses can increase blood flow to the area and worsen the condition by promoting clot dislodgement.
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A nurse is reviewing the results of an arterial blood gas analysis of a client who has chronic obstructive pulmonary disease. Which of the following results should the nurse expect?
- A. PaO2 of 95 mm Hg
- B. PaCO2 of 55 mm Hg
- C. HCO3 of 24 mEq/L
- D. pH level of 7.35
Correct Answer: B
Rationale: In chronic obstructive pulmonary disease, there is impaired gas exchange, leading to retention of carbon dioxide (CO2) and subsequent respiratory acidosis. A PaCO2 of 55 mm Hg is higher than the normal range (35-45 mm Hg) and is indicative of respiratory acidosis in COPD. Choices A, C, and D are not typically associated with COPD. PaO2 may be decreased, HCO3 may be elevated to compensate for acidosis, and pH may be lower than 7.35 due to respiratory acidosis in COPD.
A client with heart failure is being taught about dietary modifications by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will increase my intake of canned vegetables.
- B. I will limit my daily sodium intake to 2 grams.
- C. I will increase my intake of whole grains.
- D. I will reduce my intake of processed meats.
Correct Answer: D
Rationale: The correct answer is 'D: I will reduce my intake of processed meats.' This choice indicates an understanding of the teaching because processed meats are high in sodium, which can worsen heart failure due to fluid retention. Choices A, B, and C do not directly address the issue of reducing sodium intake, which is crucial for clients with heart failure. Increasing canned vegetable intake (A) may not always be advisable due to potential high sodium content in canned products. Limiting sodium intake to 2 grams daily (B) is a good practice, but it's more specific to sodium restriction rather than addressing the source of sodium like processed meats. Increasing whole grains (C) is generally beneficial but does not directly relate to reducing sodium intake in heart failure clients.
What is the most important nursing intervention for a patient experiencing an acute asthma attack?
- A. Administer bronchodilators
- B. Provide supplemental oxygen
- C. Start IV fluids
- D. Monitor oxygen saturation
Correct Answer: A
Rationale: The correct answer is to administer bronchodilators. During an acute asthma attack, bronchodilators like albuterol are crucial to help dilate the airways and improve breathing. Providing supplemental oxygen (Choice B) may be necessary but is not the priority intervention. Starting IV fluids (Choice C) and monitoring oxygen saturation (Choice D) are important aspects of care but are not the most critical interventions during an acute asthma attack.
A nurse is assessing a client who has diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Hypoglycemia
- C. Diaphoresis
- D. Tachycardia
Correct Answer: A
Rationale: Polyuria is the excessive production of urine and is a common finding in clients with hyperglycemia due to increased glucose levels. High blood sugar levels lead to the body trying to eliminate the excess glucose through urine, resulting in increased urination. Hypoglycemia (choice B) is low blood sugar and is not typically associated with hyperglycemia. Diaphoresis (choice C) is excessive sweating and is not a direct symptom of hyperglycemia. Tachycardia (choice D) is increased heart rate and is not a primary finding in hyperglycemia.
Which laboratory test is essential for monitoring renal function in a patient with chronic kidney disease?
- A. Monitor BUN and creatinine levels
- B. Check blood glucose levels
- C. Monitor hemoglobin and hematocrit levels
- D. Monitor liver enzymes
Correct Answer: A
Rationale: The correct answer is to monitor BUN (Blood Urea Nitrogen) and creatinine levels in a patient with chronic kidney disease. These tests provide crucial information about renal function. Checking blood glucose levels (Choice B) is important for monitoring diabetes, not renal function. Monitoring hemoglobin and hematocrit levels (Choice C) helps assess anemia, not specifically renal function. Monitoring liver enzymes (Choice D) is relevant for assessing liver function, not renal function.