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What is the most important nursing assessment for a patient with suspected deep vein thrombosis (DVT)?
- A. Check for leg pain
- B. Perform Homan's sign test
- C. Monitor for redness
- D. Assess for warmth and swelling
Correct Answer: A
Rationale: The most important nursing assessment for a patient with suspected deep vein thrombosis (DVT) is to check for leg pain. Leg pain is a cardinal symptom of DVT and is often the initial indicator of a blood clot. While assessing for warmth, swelling, and redness are also important in DVT evaluation, leg pain is the most crucial as it can prompt further diagnostic testing and interventions. Performing Homan's sign test is no longer recommended due to its low specificity and potential to dislodge a clot, causing complications. Monitoring for redness is important but may not always be present in DVT cases. Assessing for warmth and swelling is relevant but still secondary to the assessment of leg pain in suspected DVT cases.
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Which medication is commonly prescribed for a patient with a history of heart failure?
- A. Furosemide
- B. Metoprolol
- C. Digoxin
- D. Aspirin
Correct Answer: A
Rationale: Furosemide is the correct answer. It is a common diuretic used in patients with heart failure to reduce fluid overload. Metoprolol (Choice B) is a beta-blocker often prescribed to manage heart failure symptoms by improving heart function. Digoxin (Choice C) is used in heart failure patients to help the heart beat stronger and with a more regular rhythm. Aspirin (Choice D) is not typically prescribed for heart failure but may be used in patients with heart disease for its antiplatelet effects.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report?
- A. Calcium level of 9.0 mg/dL
- B. Serum sodium level of 138 mEq/L
- C. Respiratory rate of 18/min
- D. Stridor
Correct Answer: D
Rationale: Stridor is a high-pitched sound that indicates airway obstruction and is the priority finding to report following a thyroidectomy. In this situation, airway compromise is a critical concern that requires immediate intervention to ensure adequate oxygenation. While calcium level (Choice A) and serum sodium level (Choice B) are important assessments post-thyroidectomy, they do not represent an immediate threat to the client's airway. A respiratory rate of 18/min (Choice C) falls within the normal range and does not indicate an immediate risk to the client's airway compared to the presence of stridor.
A nurse is planning care for a client who has a stage 2 pressure injury. Which of the following interventions should the nurse include?
- A. Cleanse the wound with povidone-iodine.
- B. Apply a hydrocolloid dressing.
- C. Perform debridement as needed.
- D. Keep the wound open to air.
Correct Answer: B
Rationale: The correct answer is B: Apply a hydrocolloid dressing. Applying a hydrocolloid dressing helps create a moist environment that promotes healing in clients with stage 2 pressure injuries. Choice A, cleansing the wound with povidone-iodine, is not recommended for stage 2 pressure injuries as it can be too harsh on the skin. Performing debridement as needed, as mentioned in choice C, is not typically indicated for stage 2 pressure injuries, which involve partial-thickness skin loss. Keeping the wound open to air, as stated in choice D, is also not the preferred approach for managing stage 2 pressure injuries, as maintaining a moist environment is key to promoting healing.
What is the primary nursing action for a patient with confusion post-surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Monitor vital signs
- D. Check oxygen saturation
Correct Answer: A
Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.
A client in end-stage osteoporosis is reporting severe pain, with a respiratory rate of 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client?
- A. Promethazine
- B. Hydromorphone
- C. Ketorolac
- D. Amitriptyline
Correct Answer: B
Rationale: In a client with severe pain like the one described, the priority medication to administer is a potent analgesic like hydromorphone. Hydromorphone is a strong opioid pain medication that can effectively manage severe pain. Promethazine (Choice A) is an antiemetic and antihistamine, not a pain medication. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that is contraindicated in end-stage renal disease due to its potential to cause kidney damage. Amitriptyline (Choice D) is a tricyclic antidepressant used for conditions like depression and neuropathic pain, but it is not the first-line treatment for severe acute pain.