Nokea
Which interventions are appropriate for venous thromboembolism prophylaxis when caring for a nonambulatory client? Select all that apply.
- A. Floating both of the heels using a pillow
- B. Apply sequential compression devices to the lower extremities
- C. Encourage range of motion exercises in the lower extremities
- D. Apply compression hose to the lower extremities
- E. Administer enoxaparin subcutaneously, as prescribed
Correct Answer: B,C,D,E
Rationale: Sequential compression, ROM exercises, compression hose, and enoxaparin prevent VTE. Heel floating reduces pressure ulcers, not VTE.
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The nurse is caring for assigned clients. Which of the following clients should the nurse identify is at the highest risk for falling?
- A. 88-year-old admitted with a chest tube secondary to pneumothorax and has a history of dementia
- B. 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide
- C. 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone
- D. 28-year-old admitted with bacteremia is receiving intravenous fluids via central line and is diaphoretic
Correct Answer: A
Rationale: The 88-year-old with dementia is at highest fall risk due to age and cognitive impairment.
The nurse in the postanesthesia care unit (PACU) cares for a client who had an appendectomy. Which of the following client assessments warrants immediate follow-up?
- A. has breath sounds that are high-pitched and crowing
- B. reports incisional pain at a level of '5' on a scale of 0 (no pain) to 10 (severe pain)
- C. has a capillary blood glucose of 115 mg/dL [70-110 mg/dL]
- D. reports persistent nausea following the administration of an anti-emetic
Correct Answer: A
Rationale: High-pitched, crowing breath sounds suggest airway obstruction or stridor, a critical finding requiring immediate intervention to ensure airway patency. Moderate pain, slightly elevated glucose, and nausea are less urgent.
The nurse is caring for a 4-year-old child who is being hospitalized due to complications from an autoimmune disorder, frequent infections, and a low white blood cell count. This child is very nervous about being in the hospital. Which intervention should the nurse implement to address this child's fears?
- A. Provide the child with a private room
- B. Encourage them to play with other children in the common area
- C. Advise the parents to only visit during visiting hours
- D. Allow the parents to stay as much as they'd like
Correct Answer: D
Rationale: Parental presence reduces fear in a hospitalized child, especially with immune compromise. A private room is ideal but not the focus, group play risks infection, and limited visits increase anxiety.
The nurse is caring for a client who is describing pain on their hand as 'throbbing and sharp.' Which type of pain is the client experiencing based on this sensory description?
- A. Somatic pain
- B. Visceral pain
- C. Ischemic pain
- D. Neuropathic pain
Correct Answer: A
Rationale: Throbbing and sharp pain describe somatic pain, arising from skin or musculoskeletal tissue. Visceral pain is dull, ischemic pain is aching, and neuropathic pain is burning or tingling.
The nurse is caring for a group of premature infants. Which action is most important in preventing healthcare-acquired infection?
- A. Performing frequent hand hygiene
- B. Disinfecting commonly touched surfaces
- C. Screening visitors for illness
- D. Administer prophylactic antibiotics
Correct Answer: A
Rationale: Frequent hand hygiene is the most effective measure to prevent healthcare-acquired infections in vulnerable populations like premature infants.