Nokea
The nurse is discharging a client diagnosed with DVT from the hospital. Which discharge instructions should be provided to the client?
- A. Have the PTT levels checked weekly until therapeutic range is achieved.
- B. Staying at home is best, but if traveling, airplanes are better than automobiles.
- C. Avoid green, leafy vegetables and notify the HCP of red or brown urine.
- D. Wear knee stockings with an elastic band around the top.
Correct Answer: C
Rationale: Warfarin for DVT requires avoiding variable green leafy vegetables (vitamin K) and reporting bleeding (red/brown urine) (C). PTT (A) is for heparin, travel (B) is incorrect (movement encouraged), and knee stockings (D) increase clot risk.
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The client with varicose veins asks the nurse, 'What caused me to have these?' Which statement by the nurse would be most appropriate?
- A. You have incompetent valves in your legs.'
- B. Your legs have decreased oxygen to the muscle.'
- C. There is an obstruction in the saphenous vein.'
- D. Your blood is thick and can’t circulate properly.'
Correct Answer: A
Rationale: Varicose veins result from incompetent venous valves (A), causing pooling. Low oxygen (B) is arterial, obstruction (C) is not typical, and thick blood (D) is incorrect.
Which diagnostic test should the nurse expect for a client with suspected pericarditis?
- A. Electrocardiogram (ECG)
- B. Complete blood count (CBC)
- C. D-dimer test
- D. Chest X-ray
Correct Answer: A
Rationale: An ECG can show characteristic ST-segment elevation in pericarditis due to pericardial inflammation.
The HCP prescribes an HMG-CoA reductase inhibitor (statin) medication to a client with CAD. Which should the nurse teach the client about this medication?
- A. Take this medication on an empty stomach.
- B. This medication should be taken in the evening.
- C. Do not be concerned if muscle pain occurs.
- D. Check your cholesterol level daily.
Correct Answer: B
Rationale: Statins are most effective in the evening (B) due to cholesterol synthesis peaking at night. Food (A) enhances absorption, muscle pain (C) requires reporting, and daily checks (D) are unnecessary.
When the nurse is planning the client's postoperative care, which action is the highest priority?
- A. Providing the client with protein-rich foods
- B. Ambulating the client frequently
- C. Monitoring for wound infection
- D. Assessing for frequent leg cramping
Correct Answer: C
Rationale: Monitoring for wound infection is critical post-surgery to prevent complications and ensure healing.
The client is one (1) day postoperative abdominal aortic aneurysm repair. Which information from the unlicensed assistive personnel (UAP) would require immediate intervention from the nurse?
- A. The client refuses to turn from the back to the side.
- B. The client’s urinary output is 90 mL in six (6) hours.
- C. The client wants to sit on the side of the bed.
- D. The client’s vital signs are T 98, P 90, R 18, and BP 130/70.
Correct Answer: B
Rationale: Urine output of 90 mL in 6 hours (B) (<30 mL/hr) suggests renal compromise, requiring immediate intervention. Refusing to turn (A), sitting (C), and normal vitals (D) are less urgent.