Nokea
The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following would be an appropriate nursing goal for this client?
- A. Decrease inflammatory response in the affected extremity and prevent embolus formation.
- B. Increase peripheral circulation and oxygenation of the affected extremity.
- C. Prepare the client and family for anticipated vascular surgery on the affected extremity.
- D. Prevent hypoxia associated with the development of a pulmonary embolus.
Correct Answer: A
Rationale: important to prevent the complication of pulmonary embolism in clients at high risk
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The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?
- A. A client with chronic renal failure complaining of swollen fingers and ankle edema.
- B. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing.
- C. A client with type I diabetes mellitus who states, 'I have this quivering feeling in my abdomen.'
- D. A client on high doses of antibiotics for a resistant infection who complains of diarrhea.
Correct Answer: C
Rationale: indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk
A four-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by his mother. Which of the following statements would the nurse expect the mother to make about her son's symptoms?
- A. My son's bowel movements have turned black and sticky.
- B. I really have to encourage my son to suck the bottle.
- C. My son is fussy and seems hungry all the time.
- D. My son spits up green liquid after feeding.
Correct Answer: C
Rationale: becomes lethargic, dehydrated, and malnourished
While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority?
- A. The medication should be taken once a day for six weeks.
- B. The medication should be taken with orange juice.
- C. The medication should be taken in the morning and at bedtime.
- D. The medication should be taken with meals.
Correct Answer: D
Rationale: will decrease GI upset
An 8-year-old client is returned to the recovery room after a bronchoscopy.
- A. How should the nurse position an 8-year-old client after a bronchoscopy?
- B. In semi-Fowler’s position.
- C. Prone, with the head turned to the side.
- D. With the head of the bed elevated 45° and the neck extended.
- E. Supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position promotes lung expansion and reduces the risk of airway obstruction from edema or secretions post-bronchoscopy. Prone positioning limits respiratory assessment, neck extension risks airway obstruction, and supine does not optimize breathing.
A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective?
- A. Lemonade.
- B. Prune juice.
- C. Milk.
- D. Orange juice.
Correct Answer: B
Rationale: promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon