Nokea
The nurse is caring for a client with a diagnosis of deep vein thrombosis (DVT). Which of the following interventions is most appropriate?
- A. Applying cold packs to the affected leg.
- B. Encouraging ambulation every hour.
- C. Administering heparin as ordered.
- D. Elevating the leg above heart level.
Correct Answer: C,D
Rationale: Heparin prevents clot extension in DVT, and elevating the leg reduces swelling and promotes venous return.
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The current focus of performance improvement activities is to facilitate and address:
- A. Sound structures like policies and procedures
- B. Processes and how they are being done
- C. Optimal client outcomes
- D. Optimal staff performance
Correct Answer: C
Rationale: Performance improvement activities focus on achieving optimal client outcomes by improving the quality and safety of care delivery.
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown below (see figure). The nurse identifies this rhythm as:
- A. Atrial fibrillation.
- B. Atrial tachycardia.
- C. Premature ventricular contractions.
- D. Ventricular tachycardia.
Correct Answer: C
Rationale: Premature ventricular contractions (PVCs) are characterized by early, wide QRS complexes on an ECG, common post-myocardial infarction. The other rhythms have distinct ECG patterns not described here.
A client with a diagnosis of chronic kidney disease is prescribed a low-phosphorus diet. Which of the following foods should the nurse instruct the client to avoid?
- A. White bread.
- B. Chicken.
- C. Milk.
- D. Apples.
Correct Answer: C
Rationale: Milk is high in phosphorus and should be avoided in a low-phosphorus diet for chronic kidney disease.
Which of the following clients is at greatest risk for extravasation?
- A. The client with heart failure who is receiving Ringer's lactate
- B. The client with cancer who is receiving bendamustine
- C. The client who is receiving potassium supplementation intravenously
- D. The client who is receiving total parenteral nutrition
Correct Answer: B
Rationale: Bendamustine, a chemotherapy drug, is a vesicant, posing a high risk for extravasation, which can cause severe tissue damage if it leaks into surrounding tissues.
A female client is treated for trichomoniasis with metronidazole (Flagyl). The nurse instructs the client that:
- A. The medication should not alter the color of the urine.
- B. She should discontinue oral contraceptive use during this treatment.
- C. She should avoid alcohol during treatment and for 24 hours after completion of the drug.
- D. Her partner does not need treatment.
Correct Answer: C
Rationale: Metronidazole can cause a disulfiram-like reaction with alcohol, so avoiding alcohol during and 24 hours after treatment is critical.