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A client with deep vein thrombosis (DVT) is receiving heparin therapy. What is the priority assessment for the nurse?
- A. Monitoring blood pressure
- B. Checking the activated partial thromboplastin time (aPTT)
- C. Assessing for signs of bleeding
- D. Measuring calf circumference
Correct Answer: C
Rationale: The correct answer is C: Assessing for signs of bleeding. This is the priority assessment because heparin therapy increases the risk of bleeding. Signs of bleeding include bruising, petechiae, blood in urine or stool, and excessive bleeding from wounds. Monitoring blood pressure (A) is important but not the priority in this situation. Checking aPTT (B) is important for evaluating the effectiveness of heparin therapy but does not take precedence over assessing for bleeding. Measuring calf circumference (D) is used to detect changes in calf size due to DVT but is not the priority assessment while the client is on heparin therapy.
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When assessing a client with anxiety disorder, what does the nurse observe for evidence of various levels of anxiety?
- A. Absence of crying
- B. Talking excessively
- C. Being motionless
- D. Not complaining
Correct Answer: B
Rationale: Excessive talking may indicate heightened anxiety as the client attempts to distract themselves from their worries.
A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?
- A. Administer an IV fluid bolus.
- B. Check the surgical site for bleeding.
- C. Place the client in a Trendelenburg position.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Check the surgical site for bleeding. This is the first action the nurse should take as a sudden drop in blood pressure postoperatively could indicate internal bleeding, a common complication after abdominal surgery. By assessing the surgical site for bleeding, the nurse can identify and address the source of the hypotension promptly. Administering IV fluids (choice A) may be necessary but should come after determining the cause. Placing the client in Trendelenburg position (choice C) is not recommended as it can worsen venous return and increase intracranial pressure. Notifying the healthcare provider (choice D) should be done after the nurse has assessed the situation and taken immediate action.
After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
- B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.
Correct Answer: C
Rationale: Step 1: Wheezes indicate narrowing of the airways, typically seen in conditions like asthma.
Step 2: Inhaled bronchodilators help dilate the airways, relieving wheezing and improving breathing.
Step 3: Hence, administering an inhaled bronchodilator is the correct intervention for wheezes.
Summary:
A: Increasing oxygen flow does not directly address the issue of wheezes.
B: Encouraging coughing does not address the narrowing of airways seen with wheezes.
D: Deep breathing does not specifically target the narrowing of airways associated with wheezes.
Match the following care planning tools to the description statement(s). There may be more than one statement per tool and some statements may be used more than once.
- A. Nursing Care Plan
- B. Concept Maps
- C. Clinical Pathway
- D. All
Correct Answer: A
Rationale: Nursing Care Plans direct teams, Concept Maps visualize relationships, and Clinical Pathways guide predictable cases.
A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?
- A. Monitoring urine output
- B. Checking blood glucose levels
- C. Assessing for chest pain
- D. Monitoring electrolyte levels
Correct Answer: C
Rationale: The correct answer is C: Assessing for chest pain. The priority assessment for a client post-MI is to monitor for any signs of recurrent chest pain or angina, as it could indicate ongoing cardiac ischemia or a new infarction. Prompt intervention is crucial in these situations to prevent further damage to the heart muscle. Monitoring urine output (A) and electrolyte levels (D) are important assessments but do not take precedence over assessing for chest pain. Checking blood glucose levels (B) is relevant for diabetic clients but is not the priority in this case.