Nokea
The nurse is caring for a client who is reporting pain in their left lower leg. How should the nurse assess for the presence of thrombophlebitis?
- A. By palpating the skin over the tibia and fibula
- B. By documenting daily calf circumference measurements
- C. By recording vital signs obtained four times a day
- D. By noting difficulty with ambulation
Correct Answer: B
Rationale: Measuring calf circumference detects swelling, a key sign of thrombophlebitis, indicating possible deep vein thrombosis.
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The nurse is caring for a client with myocardial infarction (MI), who is receiving tissue plasminogen activator (tPA), the nurse should plan to prioritize which of the following?
- A. Observe for neurological changes
- B. Monitor for any signs of renal failure
- C. Observe for signs of bleeding
- D. Check the client's food diary
Correct Answer: C
Rationale: tPA is a thrombolytic that increases bleeding risk. Monitoring for signs of bleeding (e.g., hematoma, gastrointestinal bleeding) is critical.
The nurse in the emergency department (ED) is assessing a client who may have an acute myocardial infarction. Which of the following findings would support this diagnosis?
- A. U-waves
- B. T-wave inversion
- C. ST-segment elevation
- D. Prolonged PR-interval
Correct Answer: C
Rationale: ST-segment elevation on ECG is a hallmark of acute myocardial infarction, indicating myocardial ischemia.
The following scenario applies to the next 1 items
The nurse cares for a client admitted for a myocardial infarction
Item 1 of 1
Nurses' Note
0800 - Client was found in bed pale and diaphoretic, stating, I do not feel well. Approximately two minutes later, the cardiac monitor showed ventricular tachycardia. Upon assessment, the client became unresponsive and did not have a pulse.
For each potential intervention, click to specify if it is essential or contraindicated: A. Call a code blue, B. Cardiovert the client, C. Defibrillate the client, D. Anticipate a prescription for intravenous digoxin, E. Perform chest compressions
- A. Call a code blue
- B. Cardiovert the client
- C. Defibrillate the client
- D. Anticipate a prescription for intravenous digoxin
- E. Perform chest compressions
Correct Answer: A,C,E
Rationale: A: Essential - Calling a code blue activates the emergency response team for immediate intervention. B: Contraindicated - Cardioversion is used for synchronized shocks in stable rhythms like atrial fibrillation, not for pulseless ventricular tachycardia. C: Essential - Defibrillation is the treatment for pulseless ventricular tachycardia to restore a viable rhythm. D: Contraindicated - Digoxin is not used in acute cardiac arrest; it is for heart failure or rate control in arrhythmias. E: Essential - Chest compressions are required in pulseless clients as part of CPR.
The following scenario applies to the next 1 items
The nurse in the outpatient clinic is caring for a 37-year-old male client
Item 1 of 1
Nurses' Note Physician Orders Current Medications
1100: The client reports intermittent dizziness that started following the dosage increase of his prescribed spironolactone one week ago. The client states that it is worse for a few hours after he takes the medication but then resolves. On assessment, the client is alert and oriented. The client's breathing is unlabored and has clear lung fields bilaterally. Skin warm to the touch and pink in tone; pulses 2+ and regular. Capillary refill is 3 seconds. He denies any pain.
Vital signs: T 98.6° F (37° C), P 76, RR 16, BP 130/86, pulse oximetry reading 98% on room air. Medical history of hypertension and hyperlipidemia.
The nurse prepares to obtain the client's orthostatic blood pressure (BP) by first positioning the client …………. then positioning the client …………. the client …………. When obtaining the blood pressure, the nurse should ……………….. The nurse should be concerned for orthostatic hypotension if the systolic blood pressure decreases by ………….. or the diastolic blood pressure decreases by……………….
- A. Standing
- B. Supine
- C. Sitting
- D. Obtain the blood pressure with the client's arm in the dependent position.
- E. Keep the blood pressure cuff in the same position.
- F. Obtain BP readings 10 minutes after the client changes position.
- G. 20 mm Hg
Correct Answer: B,C,A,E,G
Rationale: Orthostatic BP is measured supine (B), then sitting (C), then standing (A). The cuff should stay in the same position (E). A drop of 20 mm Hg systolic (G) or 10 mm Hg diastolic
The nurse is performing an assessment on a client with congestive heart failure demonstrating ineffective coping. The nurse should plan to
- A. recommend a support group.
- B. review dietary items low in sodium.
- C. review the client's vaccination status.
- D. recommend the client take St. John's Wort.
Correct Answer: A
Rationale: A support group addresses ineffective coping by providing emotional support and coping strategies.