Nokea
The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minutes, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?
- A. Notify the physician.
- B. Administer a sedative.
- C. Try to elicit a positive Homan's sign.
- D. Increase the flow rate of intravenous fluids.
Correct Answer: A
Rationale: These symptoms suggest a possible pulmonary embolism, a life-threatening complication of DVT, requiring immediate physician notification.
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You are the chair person for the healthcare facility's newly formed multidisciplinary Safety Committee. During the Forming stage of this group's development major conflicts have arisen. Which technique of conflict resolution should you use to resolve these conflicts?
- A. Passivity
- B. Compromise
- C. Competition
- D. Accommodating Others
Correct Answer: B
Rationale: During the Forming stage, where group members are establishing relationships, compromise is the most effective conflict resolution technique to promote collaboration and consensus while addressing conflicts constructively.
Which of the following techniques is correct when administering a subcutaneous injection?
- A. Use a 1-inch needle for injection.
- B. Insert the needle at a 45-degree angle to the skin.
- C. Spread the skin tightly at the injection site.
- D. Draw 0.2 mL of air into the syringe before administration.
Correct Answer: B
Rationale: A subcutaneous injection is correctly administered at a 45-degree angle (or 90 degrees for obese patients) using a 5/8-inch needle, pinching the skin, without an air bubble.
A client with a history of osteoporosis is prescribed alendronate (Fosamax). The nurse should instruct the client to take the medication:
- A. At bedtime with a snack.
- B. First thing in the morning with water.
- C. With meals to enhance absorption.
- D. With milk to reduce stomach irritation.
Correct Answer: A
Rationale: Alendronate should be taken first thing in the morning with water, on an empty stomach, to maximize absorption and minimize esophageal irritation.
A client is scheduled for a creatinine clearance test. Which one of the following preparations is appropriate for the nurse to make?
- A. Instruct the client about the need to collect urine for 24 hours.
- B. Prepare to insert an indwelling urethral catheter.
- C. Provide the client with a sterile urine collection container.
- D. Instruct the client to force fluids to 3,000 mL/day.
Correct Answer: A
Rationale: A creatinine clearance test requires a 24-hour urine collection to assess kidney function accurately, making this the appropriate preparation.
The nurse is assessing a client with a suspected cholecystitis. Which of the following findings is most indicative of this condition?
- A. Right upper quadrant pain.
- B. Left lower quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Right upper quadrant pain is a hallmark sign of cholecystitis due to gallbladder inflammation.