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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.
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Which dietary recommendation should the nurse provide to a client with hypertension?
- A. Follow the DASH diet.
- B. Increase red meat consumption.
- C. Drink caffeinated beverages daily.
- D. Use table salt liberally.
Correct Answer: A
Rationale: The DASH diet, rich in fruits, vegetables, and low-fat dairy, is proven to lower blood pressure.
The client with a mechanical heart valve reports a fever. What should the nurse do first?
- A. Administer acetaminophen.
- B. Notify the healthcare provider.
- C. Check the client's temperature again in 4 hours.
- D. Encourage fluid intake.
Correct Answer: B
Rationale: Fever may indicate endocarditis in a client with a mechanical valve, requiring immediate medical evaluation.
Which electrolyte imbalance should the nurse monitor in a client with arrhythmias?
- A. Calcium
- B. Potassium
- C. Sodium
- D. Magnesium
Correct Answer: B
Rationale: Potassium imbalances can trigger or worsen arrhythmias by affecting cardiac cell membrane potential.
The nurse is discharging a client diagnosed with DVT from the hospital. Which discharge instructions should be provided to the client?
- A. Have the PTT levels checked weekly until therapeutic range is achieved.
- B. Staying at home is best, but if traveling, airplanes are better than automobiles.
- C. Avoid green, leafy vegetables and notify the HCP of red or brown urine.
- D. Wear knee stockings with an elastic band around the top.
Correct Answer: C
Rationale: Warfarin for DVT requires avoiding variable green leafy vegetables (vitamin K) and reporting bleeding (red/brown urine) (C). PTT (A) is for heparin, travel (B) is incorrect (movement encouraged), and knee stockings (D) increase clot risk.
Which diagnostic test should the nurse expect for a client with suspected pericarditis?
- A. Electrocardiogram (ECG)
- B. Complete blood count (CBC)
- C. D-dimer test
- D. Chest X-ray
Correct Answer: A
Rationale: An ECG can show characteristic ST-segment elevation in pericarditis due to pericardial inflammation.