Nokea
Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply.
- A. Checking urine for bright blood and a dark smoky color
- B. Daily walking as a good exercise
- C. Using garlic and ginger, which may decrease bleeding time
- D. Performing foot/leg exercises and walking around the airplane cabin on long flights
- E. Prevention as the best treatment for DVT
- F. Avoiding surface bumps because the skin is prone to injury
Correct Answer: A,B,D,F
Rationale: Rationales: A) Monitoring urine for bleeding is essential on anticoagulants. B) Daily walking promotes circulation, preventing DVT recurrence. D) Foot/leg exercises and movement during flights reduce stasis. F) Avoiding bumps prevents bruising/bleeding due to anticoagulant therapy. C) Garlic and ginger may increase bleeding risk, not decrease it. E) Prevention is vague and not a specific instruction.
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The development of a culturally sensitive health education program for the socioeconomically disadvantaged requires the nurse to:
- A. Locate the program at an existing government facility.
- B. Integrate folk beliefs and traditions into the content.
- C. Prepare materials in the primary language of the program sponsor.
- D. Exclude community leaders from initial planning efforts.
Correct Answer: B
Rationale: Integrating folk beliefs and traditions ensures the program is culturally relevant and increases acceptance and effectiveness among socioeconomically disadvantaged populations.
An overweight client taking warfarin (Coumadin) has a nursing diagnosis of ineffective tissue perfusion related to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
- A. Apply lanolin or petroleum jelly to intact skin
- B. Encourage a reduced-calorie, reduced-fat diet
- C. Inspect the involved areas daily for new ulcerations
- D. Instruct the client to limit activities of daily living (ADLs)
- E. Use an electric razor to shave
Correct Answer: B,C,E
Rationale: Rationales: B) A reduced-calorie, reduced-fat diet helps manage weight and reduce atherosclerosis progression, improving arterial blood flow. C) Daily inspection for ulcerations is essential in PVD to detect early skin breakdown due to poor perfusion. E) Using an electric razor minimizes the risk of cuts and bleeding, which is critical for a client on warfarin. A) Applying lanolin or petroleum jelly is not directly related to improving tissue perfusion. D) Limiting ADLs is incorrect, as moderate activity promotes circulation unless contraindicated.
Prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. Which of the following information is most important to include in the teaching plan at this time?
- A. Teaching how to prevent hip flexion.
- B. Demonstrating coughing and deep-breathing techniques.
- C. Showing the client what an actual hip prosthesis looks like.
- D. Assessing the client's fears about the procedure.
Correct Answer: A
Rationale: Preventing hip flexion is critical to avoid dislocation post-surgery.
The nurse teaches the client with chronic cancer pain about optimal pain control. Which of the following recommendations is most effective for pain control?
- A. Get used to some pain and use a little less medication than needed to keep from being addicted.
- B. Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain.
- C. Take analgesics only when pain returns.
- D. Take enough analgesics around the clock so that you can sleep 12 to 16 hours a day to block the pain.
Correct Answer: B
Rationale: Taking analgesics around-the-clock prevents recurrent pain by maintaining steady drug levels, which is the most effective strategy for chronic cancer pain.
In addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. The nurse should assess the client further for six years of:
- A. Nephritis.
- B. Referred pain.
- C. Urine retention.
- D. Additional stone formation.
Correct Answer: B
Rationale: Groin and bladder pain in renal calculi often indicate referred pain from the stone's movement or irritation along the urinary tract.