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What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)
- A. Administering mild analgesics for pain
- B. Applying elastic compression stockings
- C. Elevating the legs when sitting or lying
- D. Reminding the client to do leg exercises
- E. Teaching the client about surgical options
Correct Answer: B,C,D
Rationale: The plan of care for varicose veins includes elastic compression stockings, exercise, and elevation. Administering analgesics is pharmacologic, and teaching about surgical options is not a comfort measure.
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A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse?
- A. Administer oxygen via non-rebreather mask
- B. Ensure the client has a patent airway
- C. Prepare to assist with suturing the artery
- D. Start two large-bore IVs with normal saline
Correct Answer: B
Rationale: Airway always takes priority, followed by breathing and circulation. Ensuring a patent airway is the first step before other interventions.
A client with peripheral artery disease (PAD) makes the following statements to the nurse. Which indicates the need for further teaching?
- A. I should avoid using heating pads on my legs
- B. I need to walk until I feel pain, then rest
- C. I should keep my legs elevated when resting
- D. It's going to be really hard but I will stop smoking
Correct Answer: A
Rationale: Clients with PAD should avoid heating pads due to decreased skin sensitivity, which can lead to burns. This statement shows understanding, so no further teaching is needed for it. The other statements align with proper PAD management.
A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)
- A. Apply compression stockings
- B. Assist with ambulation
- C. Assist with deep breathing
- D. Offer fluids frequently
- E. Teach leg exercises
Correct Answer: A,B,D
Rationale: The UAP can apply compression stockings, assist with ambulation, and offer fluids to prevent DVT. Deep breathing does not reduce DVT risk, and teaching is a nursing function.
A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client states the drug is dangerous. What action by the nurse is best?
- A. Assess the reason behind the client's fear
- B. Remind the client about laboratory monitoring
- C. Tell the client drugs are safer today than before
- D. Warn the client about consequences of noncompliance
Correct Answer: A
Rationale: The first step is to assess the reason behind the client's fear, which may be related to a past experience. Addressing the specific concern is critical for effective teaching and compliance. The other options do not address the client's fear directly.
A nurse wants to provide community service that helps meet the goals of Healthy People 2020 related to cardiovascular disease and stroke. What activity would best meet this goal?
- A. Teach a class on heart-healthy diets
- B. Participate in blood pressure screenings at the mall
- C. Provide pamphlets on heart disease at the grocery store
- D. Set up an information booth at the pet store
Correct Answer: B
Rationale: An important goal of Healthy People 2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether it was normal or high. Blood pressure screenings in a public place best meet this goal.