Nokea
The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply.
- A. Place sequential compression devices on both legs.
- B. Instruct the client to stay in bed and not ambulate.
- C. Encourage fluids and a diet high in roughage.
- D. Monitor IV site every four (4) hours and prn.
- E. Assess Homans’ sign every 24 hours.
Correct Answer: A,C,D
Rationale: Compression devices (A), fluids/fiber (C), and IV monitoring (D) prevent DVT progression and complications. Bedrest (B) is not absolute (early ambulation is encouraged), and Homans’ sign (E) is unreliable.
You may also like to solve these questions
The nurse is assessing a client with hypertension. Which finding requires immediate action?
- A. Blood pressure of 160/100 mmHg
- B. Headache rated 4/10
- C. Blurred vision and confusion
- D. Pulse rate of 88 beats per minute
Correct Answer: C
Rationale: Blurred vision and confusion indicate a hypertensive crisis, which can lead to organ damage and requires immediate intervention.
The client with a pacemaker asks how to check if it is working. What is the best response?
- A. Check your pulse regularly.
- B. Monitor your blood pressure daily.
- C. Weigh yourself every morning.
- D. Measure your temperature daily.
Correct Answer: A
Rationale: Checking the pulse ensures the pacemaker is maintaining an appropriate heart rate.
The client diagnosed with subclavian steal syndrome has undergone surgery. Which assessment data would warrant immediate intervention by the nurse?
- A. The client’s pedal pulse on the left leg is absent.
- B. The client complains of numbness in the right hand.
- C. The client’s brachial pulse is strong and bounding.
- D. The client’s capillary refill time (CRT) is less than three (3) seconds.
Correct Answer: B
Rationale: Numbness in the right hand (B) post-subclavian surgery suggests nerve or vascular compromise, requiring immediate action. Absent pedal pulse (A) is unrelated, strong brachial pulse (C) is normal, and CRT <3 sec (D) is normal.
The nurse is preparing to administer 7.5 mg of an oral anticoagulant. The medication available is 5 mg per tablet. How many tablets should the nurse administer?
Correct Answer: 1.5
Rationale: Dose required: 7.5 mg. Available: 5 mg/tablet. 7.5 ÷ 5 = 1.5 tablets. Administer 1.5 tablets (e.g., one whole and one half, if scored).
Which instruction should the nurse include for a client with heart failure to monitor fluid status?
- A. Check blood pressure twice daily.
- B. Weigh yourself every morning.
- C. Record urine color daily.
- D. Measure abdominal girth weekly.
Correct Answer: B
Rationale: Daily weight monitoring detects fluid retention early, as 1 liter of fluid equals approximately 2.2 pounds.