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An adult female client, who is an office worker, comes to the occupational health dinic with an edematous right leg twice the size of the left leg. The client reports that she is otherwise healthy, smokes 2 packs of cigarettes a day, and takes birth control pills on a regular basis. Which initial nursing action should the occupational health nurse take?
- A. Ask the client to rate her pain on a scale from 0 to 10.
- B. Teach the client to keep the leg elevated
- C. Treat with ice then apply an elastic bandage wrap.
- D. Check the leg for warmth and erythema.
Correct Answer: D
Rationale: Checking for warmth and erythema assesses for deep vein thrombosis, a serious condition indicated by unilateral leg swelling.
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A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?
- A. Implement seizure precautions.
- B. Begin straining all urine.
- C. Administer a PRN dose of a laxative.
- D. Initiate cardiac telemetry.
Correct Answer: B
Rationale: Straining urine checks for kidney stones, likely causing flank pain in hyperparathyroidism, prioritizing over other interventions.
The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take?
- A. Schedule a portable chest x-ray per PRN protocol.
- B. Maintain the current IV antibiotic schedule.
- C. Obtain a specimen of the drainage for culture.
- D. Milk' the tube to remove any clots.
Correct Answer: C
Rationale: A culture of the changed drainage assesses for infection or other causes, prioritizing over imaging, antibiotics, or tube manipulation.
A client with heart failure (HF) returns to the clinic two weeks after adjustments were made to the prescribed cardiac glycoside, diuretic, and potassium supplement. The client's lungs are clear, heart rate is 58 beats/minute, and serum potassium level is 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?
- A. Compare the weight with what it was at last visit.
- B. Report serum potassium to healthcare provider.
- C. Review the dietary history from the past week.
- D. Check the pretibial areas and ankles for edema.
Correct Answer: B
Rationale: Reporting hypokalemia (2.9 mEq/L) is critical to prevent arrhythmias, especially with cardiac glycosides.
After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?
- A. Obtain current vital signs.
- B. Measure abdominal girth.
- C. Observe for flushing
- D. Auscultate breath sounds.
Correct Answer: A
Rationale: Vital signs assess hemodynamic stability, critical for potential gastrointestinal bleeding indicated by coffee-ground emesis, prioritizing over other assessments.
Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?
- A. Limit intake of chips and pretzels.
- B. Encourage mountain biking.
- C. Elevate lower extremities.
- D. Restrict fluid intake to water.
Correct Answer: C
Rationale: Elevating lower extremities reduces venous pressure and promotes blood return, directly improving circulation in chronic venous insufficiency.