Nokea
Which of the following nursing interventions is most helpful in promoting venous circulation?
- A. Offer the client an analgesic for pain.
- B. Apply elastic compression stockings.
- C. Encourage complete bedrest for 48 hours.
- D. Teach the client to sit with legs dependent.
Correct Answer: B
Rationale: Elastic compression stockings promote venous return by applying graduated pressure, reducing edema and improving circulation.
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The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVT following hip replacement surgery complains to the nurse that there are small purple hemorrhagic areas on the upper abdomen. Which action should the nurse implement?
- A. Notify the HCP immediately.
- B. Check the client’s PTT level.
- C. Explain this results from the medication.
- D. Assess the client’s vital signs.
Correct Answer: C
Rationale: Small hemorrhagic areas (C) are expected with LMWH due to subcutaneous bleeding. Notifying HCP (A), checking PTT (B) (not used for LMWH), or vitals (D) are unnecessary unless severe bleeding occurs.
The nurse is assessing a client with heart failure. Which finding indicates worsening condition?
- A. Weight gain of 3 pounds in 2 days
- B. Blood pressure of 120/80 mmHg
- C. Heart rate of 70 beats per minute
- D. Clear lung sounds bilaterally
Correct Answer: A
Rationale: Rapid weight gain in heart failure indicates fluid retention, a sign of worsening condition.
When offered the pain medication, the client says to the nurse, 'If that's Motrin, I don't want it. It makes me sick to my successful,' What is the most appropriate nursing action at this time?
- A. Tell the client that the drug is ibuprofen.
- B. Explain that the prescribed medication must be taken.
- C. Advise the client to take the drug with plenty of water.
- D. Report the information to the charge nurse.
Correct Answer: D
Rationale: Reporting the client's adverse reaction to the charge nurse ensures proper communication and potential adjustment of the medication plan.
Which assessment finding in a client with a pacemaker requires immediate action? Select all that apply.
- A. Heart rate of 50 beats per minute
- B. Pain at the insertion site
- C. Fever of 101°F
- D. Hiccups that persist
- E. Swelling at the pacemaker site
- F. Mild bruising at the site
Correct Answer: A,C,D,E
Rationale: Low heart rate, fever, persistent hiccups, and swelling suggest pacemaker malfunction or infection, requiring immediate attention.
The client with varicose veins is six (6) hours postoperative vein ligation. Which nursing intervention should the nurse implement first?
- A. Assist the client to dangle the legs off the side of the bed.
- B. Assess and maintain pressure bandages on the affected leg.
- C. Apply a sequential compression device to the affected leg.
- D. Administer the prescribed prophylactic intravenous antibiotic.
Correct Answer: B
Rationale: Assessing/maintaining pressure bandages (B) prevents bleeding post-vein ligation. Dangling (A) is premature, compression devices (C) are secondary, and antibiotics (D) follow assessment.