Nokea
Select all the factors regarding a deep vein thrombosis that are included in Virchow's Triad:
- A. Hypocoagulability
- B. Atherosclerosis
- C. Endothelial damage
- D. Stasis of venous blood
- E. Excessive coagulability
- F. Increased venous blood flow
Correct Answer: C,D,E
Rationale: Virchow's Triad details the THREE factors (hence why it called a triad) for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage.
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Which question is most important for the nurse to ask the client at this time?
- A. When did you last take your prescribed medications?
- B. Have you taken all your medications as prescribed?
- C. How many drug refills have you obtained?
- D. Have you experienced any drug side effects?
Correct Answer: B
Rationale: Asking if the client has taken all medications as prescribed assesses adherence, which is critical for tuberculosis treatment efficacy.
The nurse and a licensed practical nurse (LPN) are caring for five (5) clients on a medical unit. Which clients would the nurse assign to the LPN? Select all that apply.
- A. The 32-year-old female diagnosed with exercise-induced asthma who has a forced vital capacity of 1,000 mL.
- B. The 45-year-old male with adult-onset asthma who is complaining of difficulty completing all of the ADLs at one time.
- C. The 92-year-old client diagnosed with respiratory difficulty who is beginning to be confused and keeps climbing out of bed.
- D. The 6-year-old client diagnosed with intrinsic asthma who is scheduled for discharge and the mother needs teaching about the medications.
- E. The 20-year-old client diagnosed with asthma who has a pulse oximetry reading of 95% and wants to sleep all the time.
Correct Answer: B,E
Rationale: Stable asthma clients with ADL difficulty (B) and normal SpO2 (E) are suitable for LPN care. Low FVC (A), confusion (C), and discharge teaching (D) require RN assessment.
When the nurse is instructing the client on the effectiveness of oseltamivir (Tamiflu), which of the following instruction points is essential?
- A. Tamiflu must be started within 12 to 24 hours of the first symptoms.
- B. Tamiflu must be taken on an empty stomach to aid in absorption.
- C. Tamiflu affects the liver; liver enzymes are assessed before administration.
- D. Tamiflu is most effective when administered intranasally.
Correct Answer: A
Rationale: Oseltamivir is most effective when started within 12 to 24 hours of symptom onset, as it inhibits viral replication early.
Your patient, who is receiving Pyrazinamide, report stiffness and extreme pain in the right big toe. The site is extremely red, swollen, and warm. You notify the physician and as the nurse you anticipated the doctor will order?
- A. Calcium level
- B. Vitamin B6 level
- C. Uric acid level
- D. Amylase level
Correct Answer: C
Rationale: Pyrazinamide can cause hyperuricemia, leading to gout symptoms (pain, redness, swelling in joints like the big toe). The physician will likely order a uric acid level to confirm this side effect.
When suctioning a client with a tracheostomy, when is the best time to occlude the vent on the suction catheter?
- A. Before inserting the catheter
- B. When inside the inner cannula
- C. While withdrawing the catheter
- D. When the client begins coughing
Correct Answer: C
Rationale: Occluding the vent while withdrawing the catheter applies suction to remove secretions effectively.