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In planning nursing care for a bedfast client, which factor is most likely to contribute to the development of deep vein thrombosis (DVT) in an immobile client?
- A. Atherosclerotic plaque formation.
- B. Stasis of blood flow.
- C. Endothelial damage.
- D. Atherosclerotic vessel changes.
Correct Answer: B
Rationale: The correct answer is B: Stasis of blood flow. Stasis of blood flow in immobile clients increases the risk of DVT, as lack of movement can cause blood to pool and clot. Atherosclerotic plaque formation (choice A) and atherosclerotic vessel changes (choice D) are more related to arterial diseases rather than DVT. Endothelial damage (choice C) can contribute to the development of DVT, but in an immobile client, stasis of blood flow is the most significant factor.
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A client with asthma is prescribed a metered-dose inhaler (MDI) with albuterol. Which instruction is essential for the nurse to provide?
- A. Use the inhaler only before bedtime
- B. Shake the inhaler well before use
- C. Exhale fully before inhaling the medication
- D. Take two puffs every hour
Correct Answer: B
Rationale: The correct answer is to 'Shake the inhaler well before use.' This instruction is crucial as shaking the inhaler ensures the proper mixing of the medication, which is essential for its effective delivery. Option A is incorrect because using the inhaler only before bedtime may not provide adequate relief during the day. Option C is incorrect as exhaling fully is a good practice but not the most essential instruction. Option D is incorrect as taking two puffs every hour may exceed the recommended dosage and lead to adverse effects.
The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
- A. Nuchal rigidity
- B. Carotid bruit
- C. Jugular vein distention
- D. Palpable cervical lymph node
Correct Answer: B
Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.
A client with ulcerative colitis is experiencing frequent diarrhea. What is the priority nursing diagnosis?
- A. Risk for impaired skin integrity
- B. Fluid volume deficit
- C. Imbalanced nutrition: less than body requirements
- D. Activity intolerance
Correct Answer: B
Rationale: The correct answer is B: Fluid volume deficit. In a client with ulcerative colitis experiencing frequent diarrhea, the priority nursing diagnosis is addressing the potential fluid volume deficit due to significant fluid loss. Maintaining adequate hydration is crucial to prevent complications associated with dehydration. While choices A, C, and D can also be concerns for a client with ulcerative colitis, addressing fluid volume deficit takes precedence as it directly impacts the client's physiological stability and can lead to serious complications if not managed promptly.
A client with hyperkalemia is being treated in the emergency department. Which medication should the nurse prepare to administer?
- A. Potassium chloride
- B. Calcium gluconate
- C. Magnesium sulfate
- D. Sodium bicarbonate
Correct Answer: B
Rationale: The correct answer is B, Calcium gluconate. In hyperkalemia, where potassium levels are elevated, calcium gluconate is administered to stabilize the myocardial cell membrane and protect the heart from potential arrhythmias. Potassium chloride (choice A) would worsen the condition by further increasing potassium levels. Magnesium sulfate (choice C) is not the primary treatment for hyperkalemia. Sodium bicarbonate (choice D) is used in metabolic acidosis, not specifically for hyperkalemia.
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the healthcare provider?
- A. Low-grade fever.
- B. Muscle atrophy.
- C. Hematuria.
- D. Joint pain.
Correct Answer: C
Rationale: Hematuria is the most important assessment finding to report to the healthcare provider in a client with SLE during an exacerbation. Hematuria indicates kidney involvement, a serious complication of SLE that requires prompt medical attention. While low-grade fever, muscle atrophy, and joint pain are symptoms that can occur in SLE, hematuria signifies potential renal damage, which is a critical concern in SLE exacerbations.