What is the best method to assess for fluid overload in patients with heart failure?
- A. Monitor daily weight
- B. Check for jugular vein distention
- C. Check for pitting edema
- D. Check for fluid retention
Correct Answer: A
Rationale: The correct answer is A: Monitor daily weight. Daily weight monitoring is the most accurate method to assess fluid overload in patients with heart failure. Changes in weight can indicate fluid retention before visible signs like jugular vein distention or pitting edema appear. Checking for jugular vein distention (choice B) is helpful but may not be as sensitive as daily weight monitoring. Pitting edema (choice C) and fluid retention (choice D) are signs of fluid overload, but daily weight monitoring is a more proactive approach to detect changes early.
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A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect?
- A. Increased urine output
- B. Increased serum sodium
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: C
Rationale: In clients with Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the nurse should expect hyponatremia. SIADH leads to excess water retention, diluting the sodium levels in the blood, resulting in low serum sodium levels. Choice A, increased urine output, is incorrect as SIADH causes water retention, leading to decreased urine output. Choice B, increased serum sodium, is incorrect because SIADH causes a dilutional effect due to water retention, resulting in decreased serum sodium levels. Choice D, hypercalcemia, is unrelated to SIADH and not a typical finding.
A nurse is assessing a client who has deep vein thrombosis (DVT) in the left lower extremity. Which of the following findings should the nurse expect?
- A. Pain in the right lower extremity
- B. Cold skin in the affected extremity
- C. Redness and warmth in the affected extremity
- D. Shiny skin on the affected extremity
Correct Answer: C
Rationale: Corrected Rationale: Redness and warmth are classic signs of inflammation, which are commonly seen in clients with deep vein thrombosis (DVT). These findings indicate increased blood flow and temperature in the affected area. Pain in the right lower extremity (Choice A) is not expected in a client with DVT affecting the left lower extremity. Cold skin (Choice B) is not a typical finding in DVT; instead, warmth is more indicative of inflammation. Shiny skin (Choice D) is not a common characteristic of DVT; rather, the skin may appear red, swollen, and warm due to the inflammatory process.
A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Massage the affected extremity to promote circulation.
- B. Elevate the affected extremity.
- C. Apply cold packs to the affected extremity.
- D. Perform range-of-motion exercises on the affected extremity.
Correct Answer: C
Rationale: The correct intervention for a client with DVT is to apply cold packs to the affected extremity. Cold packs can help reduce swelling and pain by constricting blood vessels. Massaging the affected extremity can dislodge a clot and worsen the condition. Elevating the affected extremity helps with blood flow but is not the priority intervention for DVT. Performing range-of-motion exercises on the affected extremity can also dislodge a clot and is contraindicated.
Which lab value is most critical to monitor in a patient receiving digoxin?
- A. Monitor potassium levels
- B. Monitor sodium levels
- C. Monitor calcium levels
- D. Monitor magnesium levels
Correct Answer: A
Rationale: The correct answer is to monitor potassium levels in a patient receiving digoxin. Hypokalemia can potentiate the toxic effects of digoxin, leading to serious cardiac arrhythmias. Monitoring potassium levels helps prevent toxicity. Monitoring sodium levels (Choice B), calcium levels (Choice C), and magnesium levels (Choice D) are also important aspects of patient care, but potassium levels are most critical in patients on digoxin therapy.
A client is at risk for developing deep vein thrombosis (DVT). Which of the following actions should the nurse take?
- A. Encourage the client to remain on bed rest.
- B. Massage the client's legs every 4 hours.
- C. Apply sequential compression devices to the client's legs.
- D. Administer anticoagulants as prescribed.
Correct Answer: C
Rationale: The correct action the nurse should take for a client at risk for developing DVT is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis by promoting circulation and reducing the risk of DVT. Encouraging the client to remain on bed rest (Choice A) can actually increase the risk of DVT due to immobility. Massaging the client's legs every 4 hours (Choice B) can dislodge blood clots and is contraindicated in DVT prevention. While administering anticoagulants as prescribed (Choice D) is a treatment for DVT, it is not a preventive measure for a client at risk.