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The nurse is caring for a client diagnosed with a deep venous thrombosis 1 day ago. Which action by the client would require an immediate intervention by the nurse?
- A. Ambulates through the hallway several times per day
- B. Applies a warm compress to the site of inflammation
- C. Elevates the limb above the level of the heart while in bed
- D. Massages the affected leg to reduce pain and swelling
Correct Answer: D
Rationale: Massaging the leg (D) risks dislodging the clot, causing embolism, requiring immediate intervention. Ambulation (A), warm compresses (B), and elevation (C) are appropriate.
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One month ago, a client was prescribed phenytoin 100 mg orally 3 times daily. The client's current serum phenytoin level is 32 mcg/mL (127 μmol/L). Which action by the health care provider does the nurse anticipate?
- A. Administer phenytoin as prescribed
- B. Decrease phenytoin daily dose
- C. Increase phenytoin daily dose
- D. Repeat serum phenytoin level in 2 hours
Correct Answer: B
Rationale: A phenytoin level of 32 mcg/mL is toxic (therapeutic range: 10-20 mcg/mL), so the dose should be decreased (B). Continuing (A) or increasing (C) the dose risks toxicity. Repeating the level (D) delays intervention.
The nurse has taught the parent of a pediatric client who will be receiving growth hormone replacement therapy. Which of the following statements by the parent would require follow-up?
- A. The medication needs to be given at bedtime to be most effective.
- B. My child will achieve a height equal to peers after receiving therapy.
- C. The medication will be discontinued when my child's bone growth ceases.
- D. Routine x-rays may be required during therapy to monitor bone lengthening.
Correct Answer: B
Rationale: Expecting equal height to peers (B) is unrealistic, as outcomes vary. Bedtime dosing (A), discontinuation at bone closure (C), and x-rays (D) are correct.
The nurse is caring for a 5 year-old child whose left leg is in skeletal traction. Which of the following activities would be an appropriate diversional activity?
- A. Kicking balloons with right leg
- B. Playing 'Simon Says'
- C. Playing hand held games
- D. Throw bean bags
Correct Answer: C
Rationale: Playing hand held games. Immobilization with traction must be maintained until bone ends are in satisfactory alignment. Activities that increase mobility interfere with the goals of treatment.
The nurse is talking with a client with hypertension and hyperlipidemia who is receiving nifedipine and simvastatin. Which of the following statements by the client would require follow-up?
- A. I need to change positions slowly when I get out of bed.
- B. I take my medications daily with a glass of grapefruit juice.
- C. I drink a glass of red wine with dinner a few times each week.
- D. I have begun seasoning my foods with fresh herbs and spices.
Correct Answer: B
Rationale: Grapefruit juice (B) inhibits CYP3A4, increasing simvastatin levels and risk of toxicity. Orthostatic precautions (A), moderate wine (C), and herbs (D) are appropriate.
A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which
- A. increase the heart rate
- B. lead to dehydration
- C. are considered aerobic
- D. may be competitive
Correct Answer: B
Rationale: lead to dehydration. The client must take in adequate fluids before and during exercise periods.