Nokea
The client with cardiomyopathy reports swelling in the legs. What should the nurse do first?
- A. Elevate the client's legs.
- B. Check the client's weight.
- C. Administer a diuretic as prescribed.
- D. Restrict all fluid intake.
Correct Answer: B
Rationale: Checking weight assesses for fluid retention, a common cause of leg swelling in cardiomyopathy.
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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 finding in a client with mitral stenosis requires immediate action?
- A. Heart rate of 100 beats per minute
- B. New onset of atrial fibrillation
- C. Blood pressure of 140/90 mmHg
- D. Mild fatigue
Correct Answer: B
Rationale: New-onset atrial fibrillation increases the risk of thromboembolism in mitral stenosis, requiring immediate intervention.
The nurse is preparing the client for an arteriogram. Which instruction is most important to include?
- A. You will need to lie flat for several hours after the procedure.
- B. You can eat a light meal before the test.
- C. Avoid moving your legs during the procedure.
- D. Take your blood pressure medication as usual.
Correct Answer: A
Rationale: Lying flat post-arteriogram prevents bleeding at the catheter insertion site, typically in the femoral artery.
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 diagnosed with a deep vein thrombosis (DVT) is prescribed a heparin drip. The solution is 40,000 units in 500 mL of D5W. The health-care provider ordered the client to receive 1,200 units per hour. At which rate should the nurse set the IV pump?
Correct Answer: 15
Rationale: Heparin concentration: 40,000 units/500 mL = 80 units/mL. Dose: 1,200 units/hr ÷ 80 units/mL = 15 mL/hr. Set pump to 15 mL/hr.