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The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?
- A. Administer intravenous antibiotics.
- B. Apply warm moist packs every two (2) hours.
- C. Elevate the right foot on two (2) pillows.
- D. Teach the client about skin and foot care.
Correct Answer: A
Rationale: Cellulitis requires immediate IV antibiotics (A) to treat infection, especially in diabetes. Warm packs (B), elevation (C), and teaching (D) follow to support healing and prevention.
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The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVT following hip replacement surgery complains to the nurse that there are small purple hemorrhagic areas on the upper abdomen. Which action should the nurse implement?
- A. Notify the HCP immediately.
- B. Check the client’s PTT level.
- C. Explain this results from the medication.
- D. Assess the client’s vital signs.
Correct Answer: C
Rationale: Small hemorrhagic areas (C) are expected with LMWH due to subcutaneous bleeding. Notifying HCP (A), checking PTT (B) (not used for LMWH), or vitals (D) are unnecessary unless severe bleeding occurs.
Which assessment finding in a client with endocarditis requires immediate action?
- A. Splinter hemorrhages under nails
- B. Mild joint pain
- C. New heart murmur
- D. Fatigue after activity
Correct Answer: C
Rationale: A new heart murmur may indicate valve damage or worsening infection, requiring urgent evaluation.
The nurse just received the a.m. shift report. Which client should the nurse assess first?
- A. The client diagnosed with coronary artery disease who has a BP of 170/100.
- B. The client diagnosed with DVT who is complaining of chest pain.
- C. The client diagnosed with pneumonia who has a pulse oximeter reading of 98%.
- D. The client diagnosed with ulcerative colitis who has non-bloody diarrhea.
Correct Answer: B
Rationale: Chest pain in DVT (B) suggests pulmonary embolism, a life-threatening emergency. Hypertension (A) is urgent but less immediate, SpO2 98% (C) is normal, and diarrhea (D) is non-emergent.
The nurse is assessing a client with heart failure. Which finding indicates worsening condition?
- A. Weight gain of 3 pounds in 2 days
- B. Blood pressure of 120/80 mmHg
- C. Heart rate of 70 beats per minute
- D. Clear lung sounds bilaterally
Correct Answer: A
Rationale: Rapid weight gain in heart failure indicates fluid retention, a sign of worsening condition.
The client is four (4) hours postoperative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?
- A. Assist the client to ambulate.
- B. Assess the client's bilateral pedal pulses.
- C. Maintain a continuous IV heparin drip.
- D. Provide a clear liquid diet to the client.
Correct Answer: B
Rationale: Assessing pedal pulses (B) monitors graft patency post-AAA repair, critical at 4 hours. Ambulation (A) is premature, heparin (C) is not routine, and diet (D) awaits bowel function.