Nokea
Following femoral catheterization for percutaneous coronary intervention (PCI), the client has increasing pain in the catheterization site, and the nurse notes visible edema and induration surrounding the site. The nurse suspects a hematoma and notifies the physician. Which of the following interventions does the nurse anticipate? Select all that apply.
- A. Apply pressure to the site.
- B. Mark margins of edematous, indurated area.
- C. Monitor hemoglobin and hematocrit.
- D. Maintain bedrest.
- E. Administration of clotting factors.
Correct Answer: A,B,C,D
Rationale: Hematoma management includes applying pressure (A), marking edema (B), monitoring hemoglobin/hematocrit (C), and maintaining bedrest (D). Clotting factors (E) are not typically needed.
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The nurse is preparing to administer a dose of morphine sulfate to a client with postoperative pain. The client’s respiratory rate is 10 breaths per minute. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer half the dose and monitor the client.
- D. Recheck the respiratory rate in 30 minutes.
Correct Answer: B
Rationale: a respiratory rate of 10 breaths per minute is low, and morphine can further depress respiration, so the dose should be withheld
The nurse is preparing to discharge a client diagnosed with gout. Which statement by the client indicates understanding of dietary restrictions while managing gout?
- A. I should avoid beer, anchovies, and liver.
- B. I should avoid bananas, grapefruit, and oranges.
- C. I should avoid dairy products such as milk and ice cream.
- D. I should avoid red wine, dark chocolate, and aged cheeses.
Correct Answer: A
Rationale: Beer, anchovies, and liver are high in purines, which exacerbate gout. Other foods listed are not primary triggers.
A 42-year-old female has thrombocytopenia with a platelet count of 75,000. The nurse should
- A. monitor for bleeding.
- B. place the client on neutropenic precautions.
- C. limit visiting hours.
- D. encourage a diet high in iron.
Correct Answer: A
Rationale: Thrombocytopenia (platelets <150,000) increases bleeding risk. Monitoring for bleeding (e.g., bruising, petechiae) is the priority.
A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should:
- A. Request that foods be served with disposable utensils
- B. Ask the client to wear a mask when visitors are present
- C. Prep IV sites with mild soap and water and alcohol
- D. Provide foods in sealed, single-serving packages
Correct Answer: D
Rationale: Sealed, single-serving foods reduce infection risk in neutropenic patients.
The nurse is caring for a client with a diagnosis of major depressive disorder. Which of the following client statements would indicate that the client is responding positively to the prescribed antidepressant therapy?
- A. I feel like my energy level is starting to improve.
- B. I still don’t enjoy doing things I used to love.
- C. I have trouble sleeping through the night.
- D. I feel worthless and don’t want to see anyone.
Correct Answer: A
Rationale: improved energy level is a positive sign of response to antidepressant therapy