Nokea
The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse?
- A. The client takes a stool softener every day at dinnertime.
- B. The client is wearing a Medic Alert bracelet.
- C. The client takes vitamin E over-the-counter medication.
- D. The client has purchased a new recliner that will elevate the legs.
Correct Answer: C
Rationale: Vitamin E (C) increases bleeding risk with DVT anticoagulation, requiring intervention. Stool softeners (A), Medic Alert (B), and leg elevation (D) are appropriate.
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The client with pericarditis is prescribed ibuprofen. What is the primary purpose of this medication?
- A. Reduce fever
- B. Relieve inflammation
- C. Prevent blood clots
- D. Lower blood pressure
Correct Answer: B
Rationale: Ibuprofen reduces pericardial inflammation, alleviating pain and swelling.
The 66-year-old male client has his blood pressure (BP) checked at a health fair. The BP is 168/98. Which action should the nurse implement first?
- A. Recommend that the client have his blood pressure checked in one (1) month.
- B. Instruct the client to see his health-care provider as soon as possible.
- C. Discuss the importance of eating a low-salt, low-fat, low-cholesterol diet.
- D. Explain that this BP is within the normal range for an elderly person.
Correct Answer: B
Rationale: BP 168/98 indicates stage 2 hypertension, requiring prompt HCP evaluation (B). Waiting a month (A) delays care, diet discussion (C) is secondary, and normal range (D) is incorrect (normal is <120/80).
The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first?
- A. Check the PTT and PT/INR.
- B. Check with the HCP to see which drug should be discontinued.
- C. Administer both medications.
- D. Discontinue the heparin because the client is receiving Coumadin.
Correct Answer: A
Rationale: Check PTT (heparin) and PT/INR (warfarin) (A) to assess therapeutic levels before action. HCP check (B), administering (C), or discontinuing (D) depend on lab results (heparin often continues briefly with warfarin).
The nurse is caring for the client with chronic venous insufficiency. Which statement indicates the client understands the discharge teaching?
- A. I shouldn’t cross my legs for more than 15 minutes.'
- B. I need to elevate the foot of my bed while sleeping.'
- C. I should take a baby aspirin every day with food.'
- D. I should increase my fluid intake to 3,000 mL a day.'
Correct Answer: B
Rationale: Elevating the bed (B) reduces edema in venous insufficiency. Crossing legs (A) is discouraged entirely, aspirin (C) is for arterial issues, and 3,000 mL (D) risks fluid overload.
The client diagnosed with essential hypertension asks the nurse, 'I don’t know why the doctor is worried about my blood pressure. I feel just great.' Which statement by the nurse would be the most appropriate response?
- A. Damage can be occurring to your heart and kidneys even if you feel great.'
- B. Unless you have a headache, your blood pressure is probably within normal limits.'
- C. When is the last time you saw your doctor? Does he know you are feeling great?'
- D. Your blood pressure reflects how well your heart is working.'
Correct Answer: A
Rationale: Hypertension causes silent organ damage (heart, kidneys) (A), even without symptoms. Headaches (B) aren’t reliable, doctor visits (C) are irrelevant, and heart function (D) is vague.