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Which actions should the surgical scrub nurse take to prevent personally developing a DVT?
- A. Keep the legs in a dependent position and stand as still as possible.
- B. Flex the leg muscles and change the leg positions frequently.
- C. Wear white socks and shoes that have an elevated heel.
- D. Ask the surgeon to allow the nurse to take a break midway through each surgery.
Correct Answer: B
Rationale: Flexing muscles and changing positions (B) promote venous return, preventing DVT. Dependent position (A) increases risk, socks/heels (C) are irrelevant, and breaks (D) are impractical.
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Which question should the nurse ask the male client diagnosed with aortoiliac disease during the admission interview?
- A. Do you have trouble sitting for long periods of time?'
- B. How often do you have a bowel movement and urinate?'
- C. When you lie down, do you feel throbbing in your abdomen?'
- D. Have you experienced any problems having sexual intercourse?'
Correct Answer: D
Rationale: Aortoiliac disease can cause erectile dysfunction due to reduced pelvic blood flow, making sexual intercourse issues (D) relevant. Sitting (A), bowel/urination (B), and throbbing (C) are less specific.
The nurse is teaching the client recently diagnosed with essential hypertension. Which instruction should the nurse provide when discussing heart healthy exercise?
- A. Walk at least 30 minutes a day on flat surfaces.
- B. Perform light weight lifting three (3) times a week.
- C. Recommend high-intensity aerobics daily.
- D. Encourage the client to swim laps once a week.
Correct Answer: A
Rationale: Walking 30 minutes daily (A) is aerobic, safe, and effective for hypertension. Light weight lifting (B) is less ideal, high-intensity aerobics (C) is too strenuous, and weekly swimming (D) is insufficient.
The client with heart failure reports fatigue. Which action should the nurse take first?
- A. Encourage bedrest all day.
- B. Assess oxygen saturation.
- C. Administer a diuretic.
- D. Increase fluid intake.
Correct Answer: B
Rationale: Fatigue in heart failure may indicate hypoxemia, so assessing oxygen saturation is the priority.
Which assessment finding in a client with heart failure indicates pulmonary edema?
- A. Crackles in the lung bases
- B. Dry, nonproductive cough
- C. Bradycardia
- D. Warm, dry skin
Correct Answer: A
Rationale: Crackles in the lung bases indicate fluid in the alveoli, a hallmark of pulmonary edema.
The client with heart failure is prescribed digoxin. Which finding should the nurse report immediately?
- A. Heart rate of 58 beats per minute
- B. Potassium level of 3.2 mEq/L
- C. Blood pressure of 130/85 mmHg
- D. Respiratory rate of 18 breaths per minute
Correct Answer: B
Rationale: Hypokalemia (low potassium) increases the risk of digoxin toxicity, requiring immediate reporting.