Nokea
The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurrence? Select all that apply.
- A. Do not travel by car or airplane for at least 3-4 weeks
- B. Drink plenty of fluids daily and limit caffeine and alcohol intake
- C. Elevate legs on a footstool when sitting and dorsiflex the feet often
- D. Resume the walking or swimming exercise program as soon as possible after getting home
- E. Sit in a cross-legged yoga position for 5-10 minutes as this benefits circulation
Correct Answer: B,C,D
Rationale: To prevent DVT recurrence: stay hydrated to reduce blood viscosity, elevate legs and dorsiflex to promote venous return, and resume exercise to enhance circulation. Travel restrictions are not absolute post-resolution, and cross-legged sitting impedes venous flow.
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Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training?
- A. The child learns voluntary sphincter control through repetition
- B. Myelination of the spinal cord is completed by this age
- C. Neuronal impulses are interrupted by the ganglia
- D. The toddler can understand cause and effect
Correct Answer: B
Rationale: Myelination of the spinal cord is completed by this age, enabling voluntary sphincter control between 18 to 24 months.
A client is in suspected shock state from major trauma. Which of the following parameters indicate the adequacy of peripheral perfusion? Select all that apply.
- A. Apical pulse
- B. Capillary refill time
- C. Lung sounds
- D. Pupillary response
- E. Skin color and temperature
Correct Answer: B,E
Rationale: Capillary refill time and skin color/temperature directly assess peripheral perfusion in shock. Apical pulse , lung sounds , and pupillary response evaluate other aspects.
A client with iron deficiency anemia is started on ferrous sulfate tablets. The nurse has instructed the client on the appropriate way to take her medication. Which of the following statements indicates that the client understands the nurse's teaching?
- A. I can take my iron tablets with a glass of milk.'
- B. I need to take my iron tablets daily before breakfast.'
- C. Taking my iron tablets before I go to bed will cut down on stomach upset.'
- D. Taking my iron tablets with a glass of orange juice will help me absorb more of the medicine.'
Correct Answer: D
Rationale: Vitamin C (in orange juice) enhances iron absorption. Milk reduces absorption, and timing (breakfast or bedtime) is less critical.
A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply.
- A. Amphetamine use
- B. Cigarette smoking
- C. Cold exposure
- D. Deep sleep
- E. Sexual intercourse
Correct Answer: A,B,C,E
Rationale: Angina can be triggered by amphetamines increasing cardiac demand, smoking causing vasoconstriction, cold exposure inducing vasospasm, and sexual intercourse raising heart rate. Deep sleep typically reduces demand.
The nurse is collecting data from a client who delivered a full-term newborn vaginally 12 hours ago after prolonged labor. Which of the following findings would be essential to follow up?
- A. foul-smelling lochia
- B. external hemorrhoids
- C. temperature of 100 F (37.8 C)
- D. discomfort during fundal massage
Correct Answer: A
Rationale: Foul-smelling lochia suggests possible endometritis or infection, requiring immediate follow-up. External hemorrhoids and mild temperature elevation are common postpartum findings, and discomfort during fundal massage is expected unless accompanied by other concerning signs.