Nokea
The client at risk for thrombophlebitis receives reinforcement from the LPN/LVN regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information?
- A. I should avoid sitting for prolonged periods.
- B. I will take frequent walks and avoid prolonged bed rest.
- C. I should drink plenty of fluids to stay hydrated.
- D. I will use compression stockings as advised by my doctor.
Correct Answer: B
Rationale: The correct answer is B. Taking frequent walks and avoiding prolonged bed rest are essential measures to promote circulation and reduce the risk of thrombophlebitis. Physical activity helps prevent blood from pooling and clotting in the veins, thus decreasing the likelihood of thrombophlebitis development.
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A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?
- A. Assist the client to get back into bed.
- B. Report the chest pain episode to the healthcare provider.
- C. Tell the client to stand still and take the client's blood pressure.
- D. Give a nitroglycerin (Nitrostat) tablet and assist the client to the bathroom.
Correct Answer: A
Rationale: In a client with myocardial infarction experiencing chest pain during activity, the priority action is to stop the activity immediately to reduce the heart's workload and oxygen demand. Assisting the client back to bed helps in reducing stress on the heart and can prevent worsening of the condition. Reporting the chest pain episode to the healthcare provider is important but should not delay taking immediate action to alleviate symptoms. Taking the client's blood pressure and administering nitroglycerin are secondary actions after ensuring the client's safety and comfort.
A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation?
- A. The ulcer has a pale-colored base.
- B. The ulcer is deep, with even edges.
- C. The ulcer has little granulation tissue.
- D. The ulcer has a brownish or 'brawny' appearance.
Correct Answer: D
Rationale: When assessing a venous stasis leg ulcer, the nurse should expect to note a brownish or 'brawny' appearance. This discoloration is often due to hemosiderin deposits. This characteristic finding helps differentiate venous stasis ulcers from other types of ulcers, making it crucial for accurate diagnosis and appropriate treatment.
A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. What is the next appropriate nursing action?
- A. Administer another dose of nitroglycerin.
- B. Notify the healthcare provider immediately.
- C. Have the client lie down and stay calm.
- D. Give the client aspirin 325 mg to chew.
Correct Answer: A
Rationale: If chest pain persists after the first dose of nitroglycerin, it is appropriate to administer a second dose while continuing to monitor the client's response. Nitroglycerin is a vasodilator commonly used to relieve angina symptoms by dilating blood vessels and increasing blood flow to the heart. Reassessing the client's response and providing a second dose may be necessary to achieve adequate pain relief and improve blood flow to the heart.
An ambulatory clinic nurse is interviewing a client who is complaining of flu-like symptoms. The client suddenly develops chest pain. Which question best assists the nurse in discriminating pain caused by a non-cardiac problem?
- A. Can you describe the pain to me?
- B. Have you ever had this pain before?
- C. Does the pain get worse when you breathe in?
- D. Can you rate the pain on a scale of 1 to 10, with 10 being the worst?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is informed during shift report that a client is experiencing occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development?
- A. Hypokalemia
- B. Hypernatremia
- C. Hypochloremia
- D. Hypercalcemia
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.