Nokea
The nurse and an unlicensed assistive personnel (UAP) are bathing a bedfast client. Which action by the UAP warrants immediate intervention?
- A. The UAP closes the door and cubicle curtain before undressing the client.
- B. The UAP begins to massage and rub lotion into the client’s calf.
- C. The UAP tests the temperature of the water with the wrist before starting.
- D. The UAP collects all the linens and supplies and brings them to the room.
Correct Answer: B
Rationale: Massaging calves (B) risks dislodging a clot in a bedfast client (high DVT risk). Privacy (A), water testing (C), and supplies (D) are appropriate.
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The nurse is planning care for a client diagnosed with arterial occlusive disease. Which exercise instructions would the nurse teach the client?
- A. Have the client perform isometric exercises 30 minutes each day.
- B. Tell the client to start exercising on a stair stepper for 15 minutes.
- C. Inform the client that warm-up exercises are not necessary.
- D. Teach the client to walk in well-fitting shoes on level ground.
Correct Answer: D
Rationale: Walking on level ground in well-fitting shoes (D) promotes circulation in PAD. Isometric exercises (A) increase BP, stair steppers (B) are too strenuous, and warm-ups (C) are necessary.
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.
Which assessment finding in a client with a pacemaker requires immediate action? Select all that apply.
- A. Heart rate of 50 beats per minute
- B. Pain at the insertion site
- C. Fever of 101°F
- D. Hiccups that persist
- E. Swelling at the pacemaker site
- F. Mild bruising at the site
Correct Answer: A,C,D,E
Rationale: Low heart rate, fever, persistent hiccups, and swelling suggest pacemaker malfunction or infection, requiring immediate attention.
The client is prescribed amiodarone for an arrhythmia. Which side effect should the nurse teach the client to report?
- A. Mild nausea
- B. Blue-gray skin discoloration
- C. Increased appetite
- D. Dry mouth
Correct Answer: B
Rationale: Blue-gray skin discoloration is a serious side effect of amiodarone, indicating potential toxicity.
The nurse is administering heparin to a client with a DVT. Which laboratory value should the nurse monitor closely?
- A. International normalized ratio (INR)
- B. Activated partial thromboplastin time (aPTT)
- C. Platelet count
- D. Red blood cell count
Correct Answer: B
Rationale: Heparin's anticoagulant effect is monitored using aPTT to ensure therapeutic dosing and prevent bleeding.