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Which assessment data would warrant immediate intervention by the nurse?
- A. The client diagnosed with DVT who complains of pain on inspiration.
- B. The immobile client who has refused to turn for the last three (3) hours.
- C. The client who had an open cholecystectomy who refuses to breathe deeply.
- D. The client who has had an inguinal hernia repair who must void before discharge.
Correct Answer: A
Rationale: Pain on inspiration in DVT (A) suggests pulmonary embolism, requiring immediate action. Immobility (B), shallow breathing (C), and voiding (D) are less urgent.
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Which diagnostic test should the nurse expect for a client with suspected pericarditis?
- A. Electrocardiogram (ECG)
- B. Complete blood count (CBC)
- C. D-dimer test
- D. Chest X-ray
Correct Answer: A
Rationale: An ECG can show characteristic ST-segment elevation in pericarditis due to pericardial inflammation.
The nurse is teaching a client with pericarditis about activity restrictions. Which instruction is most appropriate?
- A. Resume normal activity immediately.
- B. Rest and avoid strenuous activity.
- C. Engage in high-intensity exercise.
- D. Lift heavy objects to build strength.
Correct Answer: B
Rationale: Rest prevents exacerbation of pericardial inflammation and promotes healing.
The client diagnosed with a deep vein thrombosis (DVT) is prescribed a heparin drip. The solution is 40,000 units in 500 mL of D5W. The health-care provider ordered the client to receive 1,200 units per hour. At which rate should the nurse set the IV pump?
Correct Answer: 15
Rationale: Heparin concentration: 40,000 units/500 mL = 80 units/mL. Dose: 1,200 units/hr ÷ 80 units/mL = 15 mL/hr. Set pump to 15 mL/hr.
The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?
- A. Administer intravenous antibiotics.
- B. Apply warm moist packs every two (2) hours.
- C. Elevate the right foot on two (2) pillows.
- D. Teach the client about skin and foot care.
Correct Answer: A
Rationale: Cellulitis requires immediate IV antibiotics (A) to treat infection, especially in diabetes. Warm packs (B), elevation (C), and teaching (D) follow to support healing and prevention.
Which intervention should the nurse include in the plan of care for a client with pericarditis? Select all that apply.
- A. Monitor for signs of cardiac tamponade.
- B. Administer anti-inflammatory medications.
- C. Encourage deep breathing exercises.
- D. Elevate the head of the bed.
- E. Restrict all physical activity.
- F. Check vital signs every 8 hours.
Correct Answer: A,B,D,E
Rationale: Monitoring for tamponade, administering anti-inflammatories, elevating the bed, and restricting activity manage pericarditis effectively.