Nokea
The plan of care for a patient recovering from hip surgery mentions prevention of deep vein thrombosis (DVT). Which aspect of the plan of care addresses this concern?
- A. Massaging the calves of the leg twice daily
- B. Explaining the need for fluid restriction after surgery
- C. Assisting the patient to change positions frequently
- D. Encouraging the patient to take the anti-embolism stockings off at night for better sleep.
Correct Answer: C
Rationale: The plan of care to prevent deep vein thrombosis should mention changing positions, dorsiflexing the feet and rotating ankles every 2 to 4 hours. Massaging the calves of the leg is contraindicated, as the massage could loosen a blood clot. There is no need to restrict fluids. Removing the stockings off at night is not an appropriate intervention, because a DVT could form.
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The nurse reminds the patient that the American Heart Association recommends a lipid study how frequently?
- A. Every 2 years
- B. Every 2 to 3 years
- C. At least every 4 years
- D. Every 4 to 6 years
Correct Answer: D
Rationale: The American Heart Association recommends a lipid study every 4 to 6 years for all Americans over the age of 20.
A patient with unstable angina should be provided with instructions to avoid which activity?
- A. Walking outside
- B. Eating red meat
- C. Swimming in warm pool
- D. Shoveling snow
Correct Answer: D
Rationale: The person with angina should be instructed to avoid exposure to cold, heavy exercise, eating heavy meals, and emotional stress.
A patient is admitted from the emergency department. The emergency department health care provider notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient has which class of heart failure?
- A. moderate heart failure.
- B. severe heart failure.
- C. congestive heart failure.
- D. negligible heart failure.
Correct Answer: B
Rationale: Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac inefficiency may develop at rest.
The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient makes which statement?
- A. I can ambulate in the hallway with this gadget on.'
- B. I always take off the telemetry device when I shower.'
- C. My EKG is being watched by one of the nurses in CCU on the home unit.'
- D. I am able to sleep just fine with this device on.'
Correct Answer: B
Rationale: Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower.
During a health interview by the home health nurse, which patient report suggests left-sided heart failure?
- A. I have to sleep in my recliner and I have this hacking cough.'
- B. I have no appetite and I have lost $3 \mathrm{lb}$ in the last week.'
- C. I have to urinate every 2 hours, even during the night.'
- D. I go barefoot most of the time because my feet are so hot.'
Correct Answer: A
Rationale: Left ventricular failure is often among the first of signs and symptoms of decreased cardiac output. The second is pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea, pulmonary crackles, hemoptysis, and cough.