Nokea
Which of the following factors increase the risk of developing deep vein thrombosis (DVT)? Select all that apply.
- A. Being underweight
- B. Smoking
- C. Having surgery
- D. Taking oral contraceptives
- E. High-protein diet
- F. Immobility
Correct Answer: B,C,D,F
Rationale: DVT risk factors include smoking (B), surgery (C), oral contraceptives (D), and immobility (F). Underweight (A) and high-protein diet (E) are not significant risks.
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A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse's assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?
- A. Adjust the room temperature
- B. Give a bolus of IV fluids
- C. Start O2
- D. Administer meperidine (Demerol) 75 mg IV push
Correct Answer: C
Rationale: A pulse oximetry of 92 indicates hypoxemia, so administering oxygen is the priority to improve oxygenation and prevent further sickling.
The registered nurse is making assignments for the day. Which client should not be assigned to the pregnant nurse?
- A. The client receiving linear accelerator radiation therapy for lung cancer
- B. The client with a radium implant for cervical cancer
- C. The client who has just been administered soluble brachytherapy for thyroid cancer
- D. The client who returned from an intravenous pyelogram
Correct Answer: B
Rationale: A radium implant emits radiation, posing a risk to the fetus, so the pregnant nurse should not care for this client.
An elderly preoperative client seems very anxious but denies concerns when the nurse asks; however, the client's son confides that the client is very superstitious and believes it is bad luck that he is in room 113. Which of the following actions is the best response?
- A. Reassure the client that the room number will not affect his surgery outcome.
- B. Contact the admissions department and request that the client be reassigned to a different room.
- C. Ask the physician for medication to relax the client.
- D. Ask the son to stay with the client to reassure him.
Correct Answer: B
Rationale: Reassigning the client to a different room (B) addresses the client's anxiety by respecting his superstitious beliefs, promoting comfort. Reassurance (A), medication (C), or family presence (D) may not fully alleviate the specific concern.
The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peaches
- C. Cucumber salad
- D. Yeast rolls
Correct Answer: C
Rationale: Cucumber salad contains seeds and roughage, which can irritate the colon in diverticulosis and should be avoided.
The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should:
- A. Give the client pain medication
- B. Assist the client in dangling her legs
- C. Have the client breathe deeply
- D. Provide the client additional fluids
Correct Answer: B
Rationale: Dangling the legs before walking helps assess for orthostatic hypotension and ensures the client is stable, reducing the risk of fainting.