Nokea
During an assessment, a healthcare professional is evaluating a client who has been on bed rest for the past month. Which of the following findings should the healthcare professional identify as an indication that the client has developed thrombophlebitis?
- A. bladder distention
- B. decreased blood pressure
- C. calf swelling
- D. diminished bowel sounds
Correct Answer: C
Rationale: Calf swelling, redness, and tenderness are classic signs of thrombophlebitis. The swelling occurs due to the formation of a blood clot in the deep veins of the calf, leading to inflammation and potential obstruction of blood flow. Bladder distention (Choice A) is more indicative of urinary retention, decreased blood pressure (Choice B) can be seen in conditions like shock, and diminished bowel sounds (Choice D) may suggest gastrointestinal issues, none of which are directly related to thrombophlebitis.
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While caring for an older adult client who is violent and attempting to disconnect her IV lines, the provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
- A. Remove the restraints one at a time
- B. Secure the restraints tightly to prevent movement
- C. Check the restraints every hour
- D. Use leather restraints for additional security
Correct Answer: A
Rationale: Removing restraints one at a time is the correct action to take when caring for a client in soft wrist restraints. This approach ensures safety and comfort while still maintaining the necessary restrictions. Choice B is incorrect as securing the restraints tightly can lead to circulatory issues and discomfort. Choice C of checking the restraints every hour is a reasonable action, but it is not the priority when compared to the correct choice of removing the restraints one at a time. Choice D of using leather restraints for additional security is unnecessary and may be more restrictive and uncomfortable for the client.
A nurse is preparing an infusion for a client who was hospitalized with deep-vein thrombosis. The orders read: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?
- A. 8 mL/hr
- B. 10 mL/hr
- C. 12 mL/hr
- D. 15 mL/hr
Correct Answer: A
Rationale: To calculate the infusion rate, use the formula: (Desired units/hr / Total units) Volume. In this case, it would be (800 units/hr / 25,000 units) 250 mL = 8 mL/hr. Therefore, the nurse should set the infusion pump at 8 mL/hr. Choice B, 10 mL/hr, is incorrect because it does not match the calculated rate. Choices C and D, 12 mL/hr and 15 mL/hr respectively, are also incorrect as they do not align with the correct calculation based on the provided data.
A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN?
- A. Creating a plan of care for a client who is recovering following a stroke.
- B. Assessing a pressure injury on a client who is on bed rest.
- C. Providing nasopharyngeal suctioning for a client who has pneumonia.
- D. Teaching a client who has asthma to use a metered-dose inhaler.
Correct Answer: C
Rationale: The correct answer is providing nasopharyngeal suctioning for a client who has pneumonia. This task falls within the practical nurse's scope of practice, as it involves direct patient care and basic interventions. Creating a plan of care for a client recovering from a stroke involves critical thinking and comprehensive assessment, which are typically responsibilities of registered nurses. Assessing a pressure injury requires specialized wound care knowledge, often performed by wound care specialists or registered nurses with wound care training. Teaching a client to use a metered-dose inhaler involves patient education and requires a thorough understanding of asthma management, making it more suitable for a registered nurse.
A client with a terminal illness is being educated by a healthcare provider about her decision to decline resuscitation in her living will. The client asks about the scenario of having difficulty breathing upon arrival at the emergency department.
- A. "We will apply oxygen through a tube in your nose."
- B. "We will perform resuscitation efforts regardless of your wishes."
- C. "You will receive only palliative care."
- D. "We will ensure your comfort measures are met as per your advance directives."
Correct Answer: A
Rationale: Choice A is correct because applying oxygen through a tube in the nose provides comfort and aligns with the client's wishes for palliative care without resuscitation. This intervention can help alleviate breathing difficulties and maintain comfort without initiating full resuscitation efforts, respecting the client's decision. Choice B is incorrect as it goes against the client's expressed wish to decline resuscitation in her living will. Choice C is not the most appropriate response as it does not directly address the client's immediate concern of difficulty breathing and lacks specificity. Choice D, although focusing on comfort measures, is less specific than the correct choice A in addressing the client's immediate need for assistance with breathing.
To use the nursing process correctly, what must the nurse do first?
- A. Obtain information about the client
- B. Develop a care plan
- C. Implement interventions
- D. Evaluate the client's outcomes
Correct Answer: A
Rationale: The first step in the nursing process is to obtain information about the client. This step involves gathering data through assessment to understand the client's needs, health status, and preferences. Developing a care plan (Choice B) comes after the assessment phase. Implementing interventions (Choice C) and evaluating client outcomes (Choice D) occur in subsequent stages of the nursing process. Therefore, the correct initial step is to gather information about the client to form a foundation for providing individualized care.