Nokea
Which nursing instruction is most beneficial in helping relieve the client's symptoms caused by varicose veins?
- A. Elevate your legs frequently during the day.
- B. Keep the room temperature above 70°F (21°C).
- C. Massage your calves when experiencing leg cramps.
- D. Modify your lifestyle to include sedentary activities.
Correct Answer: A
Rationale: Elevating the legs promotes venous return, reducing swelling and discomfort associated with varicose veins.
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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 teaching point should the nurse include for a client with heart failure?
- A. Avoid all physical activity.
- B. Report weight gain of 2 pounds or more in a day.
- C. Take extra diuretics if you feel short of breath.
- D. Eat high-sodium foods to maintain electrolytes.
Correct Answer: B
Rationale: Rapid weight gain indicates fluid retention, requiring prompt reporting to manage heart failure.
The client diagnosed with acute deep vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The healthcare provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?
- A. Discontinue the heparin drip prior to initiating the Coumadin.
- B. Check the client's INR prior to beginning Coumadin.
- C. Clarify the order with the health-care provider as soon as possible.
- D. Administer the Coumadin along with the heparin drip as ordered.
Correct Answer: D
Rationale: Heparin and warfarin are often overlapped for 3–5 days in acute DVT until warfarin’s INR is therapeutic (D). Discontinuing heparin (A) is premature, INR (B) is checked later, and clarification (C) is unnecessary.
Which medication should the nurse expect for a client with valvular heart disease and atrial fibrillation?
- A. Warfarin (Coumadin)
- B. Aspirin
- C. Metoprolol (Lopressor)
- D. Furosemide (Lasix)
Correct Answer: A
Rationale: Warfarin prevents thromboembolism in clients with valvular heart disease and atrial fibrillation.
The nurse is caring for a client diagnosed with deep vein thrombosis. Which information reported to the nurse by the unlicensed assistive personnel (UAP) requires immediate intervention?
- A. The UAP informed the nurse the client is complaining of chest pain.
- B. The UAP notified the nurse the client’s blood pressure is 100/66.
- C. The UAP reported the client is requesting to be able to take a shower.
- D. The UAP tells the nurse the client is asking for medication for a headache.
Correct Answer: A
Rationale: Chest pain in DVT (A) suggests pulmonary embolism, requiring immediate intervention. Hypotension (B), showering (C), and headache (D) are less urgent.