Nokea
The client admitted with a diagnosis of pneumonia complains of tenderness and pain in the left calf, and the nurse assesses a positive Homans’ sign. Which interventions should the nurse implement? List in order of priority.
- A. Notify the health-care provider.
- B. Initiate an intravenous line.
- C. Monitor the client’s PTT.
- D. Administer a continuous heparin infusion.
- E. Instruct the client not to get out of the bed.
Correct Answer: A,E,B,D,C
Rationale: 1. Notify HCP (A): Calf pain and positive Homans’ suggest DVT, requiring urgent evaluation. 2. Instruct bedrest (E): Prevents clot dislodgement. 3. Initiate IV (B): Prepares for heparin. 4. Administer heparin (D): Treats DVT post-order. 5. Monitor PTT (C): Ensures therapeutic heparin levels.
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The client is prescribed amiodarone for an arrhythmia. Which side effect should the nurse teach the client to report?
- A. Mild nausea
- B. Blue-gray skin discoloration
- C. Increased appetite
- D. Dry mouth
Correct Answer: B
Rationale: Blue-gray skin discoloration is a serious side effect of amiodarone, indicating potential toxicity.
The nurse is administering heparin to a client with a DVT. Which laboratory value should the nurse monitor closely?
- A. International normalized ratio (INR)
- B. Activated partial thromboplastin time (aPTT)
- C. Platelet count
- D. Red blood cell count
Correct Answer: B
Rationale: Heparin's anticoagulant effect is monitored using aPTT to ensure therapeutic dosing and prevent bleeding.
The nurse is planning care for a client diagnosed with arterial occlusive disease. Which exercise instructions would the nurse teach the client?
- A. Have the client perform isometric exercises 30 minutes each day.
- B. Tell the client to start exercising on a stair stepper for 15 minutes.
- C. Inform the client that warm-up exercises are not necessary.
- D. Teach the client to walk in well-fitting shoes on level ground.
Correct Answer: D
Rationale: Walking on level ground in well-fitting shoes (D) promotes circulation in PAD. Isometric exercises (A) increase BP, stair steppers (B) are too strenuous, and warm-ups (C) are necessary.
The health-care provider prescribes an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with essential hypertension. Which statement is the most appropriate rationale for administering this medication?
- A. ACE inhibitors prevent beta receptor stimulation in the heart.
- B. This medication blocks the alpha receptors in the vascular smooth muscle.
- C. ACE inhibitors prevent vasoconstriction and sodium and water retention.
- D. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle.
Correct Answer: C
Rationale: ACE inhibitors block angiotensin II, preventing vasoconstriction and sodium/water retention (C), thus lowering BP. Beta (A) and alpha (B) receptors are unrelated, and smooth muscle relaxation (D) is a secondary effect.
The nurse and an unlicensed assistive personnel (UAP) are bathing a bedfast client. Which action by the UAP warrants immediate intervention?
- A. The UAP closes the door and cubicle curtain before undressing the client.
- B. The UAP begins to massage and rub lotion into the client’s calf.
- C. The UAP tests the temperature of the water with the wrist before starting.
- D. The UAP collects all the linens and supplies and brings them to the room.
Correct Answer: B
Rationale: Massaging calves (B) risks dislodging a clot in a bedfast client (high DVT risk). Privacy (A), water testing (C), and supplies (D) are appropriate.