Nokea
The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
- A. Place pillows under the knees
- B. Use elastic stockings continuously
- C. Encourage range of motion and ambulation
- D. Massage the legs twice daily
Correct Answer: C
Rationale: Encourage range of motion and ambulation. Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk due to other factors.
You may also like to solve these questions
The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?
- A. I've felt the need for an afternoon nap most days this week.'
- B. I've gained 3 lb (1.36 kg) since I began taking this medication.'
- C. I've had the stomach flu for the past couple of days.'
- D. My mouth seems to be drier than usual lately.'
Correct Answer: C
Rationale: Stomach flu (C) can cause dehydration, increasing lithium toxicity risk, requiring immediate concern. Naps (A), weight gain (B), and dry mouth (D) are less urgent side effects.
The nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 6 inches (15.2 cm), the nurse notes a small amount of urine in the tubing. Which of the following actions should the nurse take next?
- A. Measure the urine output.
- B. Immediately inflate the balloon.
- C. Secure the catheter tubing to the client's leg.
- D. Continue to advance the catheter to the bifurcation.
Correct Answer: D
Rationale: Advancing to the bifurcation (D) ensures proper placement in the bladder before inflating the balloon. Measuring output (A), inflating early (B), or securing (C) are premature.
The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.
- A. Avoid rubbing or scratching the affected eye
- B. Avoid straining when having a bowel movement
- C. Expect occasional flashes of light during recovery
- D. Report any sudden pain to the health care provider
- E. Rest the eyes by refraining from reading and writing
Correct Answer: A, B, D
Rationale: Avoiding rubbing (A), straining (B), and reporting sudden pain (D) prevent complications. Flashes (C) are not expected and require reporting, and eye rest (E) is unnecessary unless specified.
A client with a pyloric obstruction is admitted to the hospital with vomiting. Which of the following blood gases would the nurse expect to see in the client with vomiting?
- A. $\mathrm{pH} 7.33, \mathrm{PCO}_2 30 \mathrm{~mm} \mathrm{Hg}$
- B. $\mathrm{pH} 7.50, \mathrm{PCO}_2 32 \mathrm{~mm} \mathrm{Hg}$
- C. $\mathrm{pH} 7.30, \mathrm{PCO}_2 50 \mathrm{~mm} \mathrm{Hg$
- D. $\mathrm{pH} 7.47, \mathrm{PCO}_2 40 \mathrm{~mm} \mathrm{Hg}$
Correct Answer: B
Rationale: Vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, indicated by a high pH (7.50) and normal to low PCO2.
The nurse reviews the ECG of a client. Which prescribed medication should the nurse suspect as the cause of the ECG findings?
- A. Captopril
- B. Carvedilol
- C. Glipizide
- D. Levothyroxine
Correct Answer: D
Rationale: Levothyroxine (D) can cause arrhythmias, which may be reflected in ECG changes. Captopril (A), Carvedilol (B), and Glipizide (C) are less likely to cause significant ECG alterations.