Nokea
When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
- A. Avoid drinking alcohol
- B. Eat more omega-3 fatty acids
- C. Exercise on a regular basis
- D. Maintain a healthy weight
- E. Stop smoking cigarettes
Correct Answer: C,D,E
Rationale: Hormonal birth control increases clotting risk. Health promotion measures to reduce PE risk include regular exercise, maintaining a healthy weight, and smoking cessation, as these address immobility, obesity, and smoking-related risks.
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The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
- A. Adherence to proper hand hygiene
- B. Administering anti-ulcer medication
- C. Elevating the head of the bed
- D. Providing oral care per protocol
- E. Suctioning the client on a regular schedule
Correct Answer: A,B,C,D
Rationale: The ventilator bundle to prevent ventilator-associated pneumonia includes hand hygiene, anti-ulcer medications, elevating the head of the bed (30"?45 degrees), and frequent oral care. Suctioning is performed as needed, not on a fixed schedule.
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)
- A. Acknowledge the frightening nature of the illness
- B. Delegate a back rub to the unlicensed assistive personnel
- C. Give simple explanations of what is happening
- D. Request a prescription for anti-anxiety medication
- E. Stay with the client and speak in a quiet, calm voice
Correct Answer: A,B,C,E
Rationale: Anxiety is common in PE. Acknowledging fears, delegating comfort measures like a back rub, providing simple explanations, and staying with the client in a calming manner are appropriate to reduce anxiety without routinely using medications, which may worsen hypoxia.
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)
- A. Client who had a reaction to contrast dye yesterday
- B. Client with a new spinal cord injury on a rotating bed
- C. Middle-aged man with an exacerbation of asthma
- D. Older client who is 1-day post hip replacement surgery
- E. Young obese client with a fractured femur
Correct Answer: B,D,E
Rationale: Risk factors for PE include prolonged immobility (spinal cord injury, post-hip surgery), obesity, and trauma (fractured femur). Contrast dye reaction and asthma are not associated with increased PE risk.
A client on the emergency department has several broken ribs. What care measure will best promote comfort?
- A. Allowing the client to choose the position in bed
- B. Humidifying the supplemental oxygen
- C. Using the proper amount of water
- D. Providing warmed blankets
Correct Answer: A
Rationale: Allowing the client to choose a position of comfort (often upright) improves both comfort and oxygenation in clients with respiratory issues like broken ribs.
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?
- A. Hemoglobin: 14.2 g/dL
- B. Platelet count: 82,000/µL
- C. Red blood cell count: 5.8 million/µL
- D. White blood cell count: 8.7/µL
Correct Answer: B
Rationale: A platelet count of 82,000/µL is low and may indicate heparin-induced thrombocytopenia (HIT), a serious side effect of heparin therapy. The other laboratory values are within normal ranges and do not suggest a serious adverse effect.