Nokea
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.
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The client diagnosed with acute deep vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The healthcare provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?
- A. Discontinue the heparin drip prior to initiating the Coumadin.
- B. Check the client's INR prior to beginning Coumadin.
- C. Clarify the order with the health-care provider as soon as possible.
- D. Administer the Coumadin along with the heparin drip as ordered.
Correct Answer: D
Rationale: Heparin and warfarin are often overlapped for 3–5 days in acute DVT until warfarin’s INR is therapeutic (D). Discontinuing heparin (A) is premature, INR (B) is checked later, and clarification (C) is unnecessary.
The client admitted with a diagnosis of pneumonia complains of tenderness and pain in the left calf, and the nurse assesses a positive Homans’ sign. Which interventions should the nurse implement? List in order of priority.
- A. Notify the health-care provider.
- B. Initiate an intravenous line.
- C. Monitor the client’s PTT.
- D. Administer a continuous heparin infusion.
- E. Instruct the client not to get out of the bed.
Correct Answer: A,E,B,D,C
Rationale: 1. Notify HCP (A): Calf pain and positive Homans’ suggest DVT, requiring urgent evaluation. 2. Instruct bedrest (E): Prevents clot dislodgement. 3. Initiate IV (B): Prepares for heparin. 4. Administer heparin (D): Treats DVT post-order. 5. Monitor PTT (C): Ensures therapeutic heparin levels.
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.
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.
When offered the pain medication, the client says to the nurse, 'If that's Motrin, I don't want it. It makes me sick to my successful,' What is the most appropriate nursing action at this time?
- A. Tell the client that the drug is ibuprofen.
- B. Explain that the prescribed medication must be taken.
- C. Advise the client to take the drug with plenty of water.
- D. Report the information to the charge nurse.
Correct Answer: D
Rationale: Reporting the client's adverse reaction to the charge nurse ensures proper communication and potential adjustment of the medication plan.