Nokea
Which interventions are appropriate when caring for a client with acute thrombophlebitis?
- A. Apply cool soaks and keep the client's leg lower than the level of the heart
- B. Increase the client's activity level and encourage leg exercises
- C. Apply cool soaks and administer nitroglycerin
- D. Apply warm soaks and elevate the client's legs higher than the level of the heart
Correct Answer: D
Rationale: To help treat thrombophlebitis, the nurse should prevent venostasis with measures such as applying warm soaks and elevating the client's legs. The client should remain on bed rest during the acute phase, after which the client may begin to walk while wearing antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants to prolong clotting time.
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The nurse is caring for a person who is admitted with progressive amyotrophic lateral sclerosis (ALS). What nursing care measure should the nurse expect to be ordered for this client?
- A. Change dressing daily
- B. Monitor IV fluids
- C. Insert indwelling catheter
- D. Chest physical therapy (PT) qid
Correct Answer: D
Rationale: ALS causes respiratory muscle weakness; chest PT helps clear secretions, preventing pneumonia. Dressings, fluids, or catheters are not primary.
The nurse is caring for a client who had knee surgery this morning. Postoperative orders include a narcotic every three to four hours as needed for operative site pain and an ice bag. At 7:00 P.M., the client asks for pain medication. He was last medicated at 3:30 P.M. What is the best initial nursing action?
- A. Administer the prescribed analgesic
- B. Assess the location and nature of the pain
- C. Refill the ice bag as needed
- D. Reposition the client
Correct Answer: B
Rationale: Assessing pain location and nature ensures the medication is appropriate for operative site pain, guiding safe administration. Administering without assessment, refilling ice, or repositioning are premature.
Mr. Smith is 67-year-old black male brought to the hospital by his wife, who stated that he fell down 20 minutes ago and has been unable to speak or move his right side since then, Mr. Smith has no significant past medical history. On exam, Mr. Smith is conscious, very anxious, his speech is garbed and unintelligible, he has a left facial droop, and he is completely right hemiphlegic.
The most likely etiology for his symptoms is:
- A. CVA
- B. Traumatic brain injury
- C. Brain tumor
- D. Alzheimer's disease
Correct Answer: A
Rationale: Symptoms of sudden speech loss, facial droop, and hemiplegia strongly suggest a cerebrovascular accident (stroke).
Ms. L had a C-section done. She delivered a healthy baby boy. On her 1st post operative day, Ms. L's roommate called the nurse & reports that Ms. L was very anxious & pale looking. Other clients were in Ms. L's room trying to help out. Upon assessment, her BP was 80/60, HR 110bpm.
The top nursing priority includes:
- A. monitor the patient's v/s & notify the doctor stat
- B. Clear the patient's immediate environment & ask other clients to move away
- C. Place the patient in flat position and check her abdominal dressing.
- D. Get the crash cart in anticipation for cardiac arrest
Correct Answer: A
Rationale: Hypotension and tachycardia suggest postpartum hemorrhage, requiring immediate physician notification.
A newborn is to receive phototherapy for hyperbilirubinemia. Which nursing action is essential?
- A. Keep the infant NPO for two hours before the treatment.
- B. Ask the mother to stay away from the infant during the treatment.
- C. Monitor the client's pulse rate very carefully.
- D. Cover the baby's eyes during the treatment.
Correct Answer: D
Rationale: Covering the eyes protects the newborn's retinas from phototherapy light, a critical safety measure.