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The nurse is caring for multiple clients. Which client should the nurse identify as having the greatest risk for developing a DVT?
- A. The client with an area of slight inflammation at the peripheral IV site with a PT of 25 seconds, INR of 2.5.
- B. The client postoperative hip arthroplasty who has venous insufficiency and is immobile; platelet count = 550,000/mm3.
- C. The client with a history of DVT admitted with chest pain and has a continuous intravenous heparin drip; PTT of 55 seconds.
- D. The client with dependent rubor, pallor upon lower-extremity elevation, and absent peripheral pulses; platelet count of 350,000/mm3.
Correct Answer: B
Rationale: Blood stasis (immobility), endothelial injury (postoperative client), and hypercoagulability (platelet count increased) suggest Virchow’s triad, which is associated with an increased risk of DVT. Other clients have prolonged coagulation times or arterial issues, reducing DVT risk.
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The nurse observes sinus tachycardia with new-onset ST segment elevation on the ECG monitor of the client reporting chest pain. Which should be the nurse’s priority intervention?
- A. Draw blood for cardiac enzymes STAT
- B. Call the cardiac catheterization laboratory
- C. Apply 1 inch of nitroglycerin paste topically
- D. Apply 4 liters of oxygen via nasal cannula
Correct Answer: D
Rationale: The nurse’s priority intervention should be to increase oxygen to the heart muscle. Applying 4 liters of oxygen via nasal cannula addresses the immediate need to improve myocardial oxygenation in an evolving MI indicated by ST elevation. Cardiac enzymes, catheterization, and nitroglycerin are secondary actions.
The nurse observes that the client, 3 days post MI, seems unusually fatigued. Upon assessment, the client is dyspneic with activity, has sinus tachycardia, and has generalized edema. Which action by the nurse is most appropriate?
- A. Administer high-flow oxygen.
- B. Encourage the client to rest more.
- C. Continue to monitor the client’s heart rhythm.
- D. Compare the client’s admission and current weight.
Correct Answer: D
Rationale: A complication of MI is HF. Signs of HF include fatigue, dyspnea, tachycardia, edema, and weight gain. Comparing admission and current weight assesses fluid retention, a key indicator of HF severity. High-flow oxygen is unnecessary without hypoxia, rest alone won’t address HF, and monitoring rhythm delays intervention.
The client with class II HF according to the New York Heart Association Functional Classification has been taught about the initial treatment plan for this disease. The nurse determines that the client needs additional teaching if the client states that the treatment plan includes which component?
- A. Diuretics
- B. A low-sodium diet
- C. Home oxygen therapy
- D. Angiotensin-converting enzyme (ACE) inhibitors
Correct Answer: C
Rationale: In class II HF, normal physical activity results in fatigue, dyspnea, palpitations, or anginal pain, but symptoms are absent at rest. Home oxygen therapy is unnecessary unless there are other comorbid conditions. Diuretics, low-sodium diet, and ACE inhibitors are standard treatments.
The client, who is a 15-pack-year cigarette smoker, has painful fingers and toes and is diagnosed with Buerger’s disease (thromboangiitis obliterans). Which measure to prevent disease progression should be the nurse’s initial focus when teaching the client?
- A. Avoid exposure to cold temperatures
- B. Maintain meticulous hygiene
- C. Abstain from all tobacco products
- D. Follow a low-saturated-fat diet
Correct Answer: C
Rationale: Buerger’s disease is an uncommon vascular occlusive disease that affects the medial and small arteries and veins, initially in the distal limbs. It is strongly associated with tobacco use, which causes vasoconstriction. The most important action to communicate to the client is that he must abstain from tobacco in all forms to prevent progression of the disease.
The nurse is giving discharge teaching to the client following aortic valve replacement surgery with a synthetic valve. The nurse evaluates that the client understands the teaching when the client states plans to take which action? Select all that apply.
- A. Use a soft toothbrush for dental hygiene.
- B. Floss teeth daily to prevent plaque.
- C. Wear loose-fitting T-shirts or tops.
- D. Use an electric razor for shaving.
- E. Consume foods high in vitamin K.
Correct Answer: A;C;D
Rationale: The client understands when stating: A) Using a soft toothbrush to reduce bleeding risk on anticoagulants; C) Wearing loose-fitting clothing to avoid incision friction; D) Using an electric razor to prevent cuts. Flossing (B) increases bleeding and endocarditis risk, and high vitamin K (E) antagonizes anticoagulants.