Nokea
The nurse is caring for the client on strict bedrest. Which intervention is priority when caring for this client?
- A. Encourage the client to drink liquids.
- B. Perform active range-of-motion exercises.
- C. Elevate the head of the bed to 45 degrees.
- D. Provide a high-fiber diet to the client.
Correct Answer: D
Rationale: High-fiber diet (D) prevents constipation, a priority in bedrest to avoid straining and DVT risk. Fluids (A) are important, active ROM (B) is incorrect (passive needed), and HOB elevation (C) is not primary.
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The nurse has just received the a.m. shift report. Which client would the nurse assess first?
- A. The client with a venous stasis ulcer who is complaining of pain.
- B. The client with varicose veins who has dull, aching muscle cramps.
- C. The client with arterial occlusive disease who cannot move the foot.
- D. The client with deep vein thrombosis who has a positive Homans’ sign.
Correct Answer: C
Rationale: Inability to move the foot in arterial disease (C) suggests acute ischemia, a priority. Ulcer pain (A), cramps (B), and Homans’ sign (D) are less urgent.
The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first?
- A. Check the PTT and PT/INR.
- B. Check with the HCP to see which drug should be discontinued.
- C. Administer both medications.
- D. Discontinue the heparin because the client is receiving Coumadin.
Correct Answer: A
Rationale: Check PTT (heparin) and PT/INR (warfarin) (A) to assess therapeutic levels before action. HCP check (B), administering (C), or discontinuing (D) depend on lab results (heparin often continues briefly with warfarin).
The client is prescribed nitroglycerin for angina. Which instruction should the nurse include?
- A. Take it every day even if you feel well.
- B. Place the tablet under your tongue.
- C. Swallow the tablet with water.
- D. Apply it as a patch on your chest.
Correct Answer: B
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption to relieve angina.
As the nurse provides discharge instructions to the client with varicose veins, which activity should the nurse suggest the client avoid?
- A. Walking in athletic shoes.
- B. Jogging a mile a day.
- C. Sitting with crossed knees.
- D. Wearing wool socks.
Correct Answer: C
Rationale: Sitting with crossed knees can compress veins, worsening venous stasis in clients with varicose veins.
The client had an abdominal aortic aneurysm repair two (2) days ago. Which intervention should the nurse implement first?
- A. Assess the client’s bowel sounds.
- B. Administer an IV prophylactic antibiotic.
- C. Encourage the client to splint the incision.
- D. Ambulate the client in the room with assistance.
Correct Answer: A
Rationale: Assessing bowel sounds (A) is first to detect ileus, common post-AAA repair. Antibiotics (B), splinting (C), and ambulation (D) follow based on assessment.