Nokea
Your patient has a deep vein thrombosis in the left lower extremity. The patient is prescribed continuous IV Heparin. Select all the nursing interventions that are appropriate for this patient:
- A. Apply cool compresses to affected extremity
- B. Measure leg circumference
- C. Massage affected extremity
- D. Elevate affected extremity above heart level
- E. Encourage frequent ambulation
- F. Monitor the patient's INR level
- G. Monitor the patient's aPTT level
Correct Answer: B,D,G
Rationale: Nursing interventions for this patient include: measuring leg circumference, elevating affected extremity above heart level, and monitoring aPTT level (for Heparin therapy). Why are the other options wrong? Option A: WARM compresses should be used, NOT cool (this will help with pain and circulation), Option C: this could dislodge the clot (NEVER massage or rub the site), Option E: the patient needs bed rest...ambulation could dislodge the clot, Option F: INR level is used to monitor Warfarin NOT Heparin, Option H: SCDs are NOT applied to an extremity with a clot because it could dislodge the clot...they are used to PREVENT blood clots.
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The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client?
- A. Daily inhaled corticosteroids.
- B. Use of a 'rescue inhaler.'
- C. Use of systemic steroids.
- D. Leukotriene agonists.
Correct Answer: B
Rationale: Mild intermittent asthma requires a rescue inhaler (B) (e.g., albuterol) for PRN use. Daily corticosteroids (A), systemic steroids (C), and leukotrienes (D) are for persistent asthma.
When teaching the client about topical nasal decongestant sprays, the nurse should warn that overuse of such medication is likely to result in which adverse effect?
- A. Nasal irritation with rhinorrhea
- B. Rebound congestion with nasal stuffiness
- C. Ulceration of the nasal mucous membranes
- D. Decreased ability to fight microorganisms
Correct Answer: B
Rationale: Overuse of topical nasal decongestants can lead to rebound congestion, where nasal passages become more congested after the medication wears off, due to dependency on the decongestant.
A patient has a PPD skin test (Mantoux test). As the nurse you tell the patient to report back to the office in so the results can be interpreted?
- A. 24-48 hours
- B. 12-24 hours
- C. 48-72 hours
- D. 24-72 hours
Correct Answer: C
Rationale: The patient should report back in 48-72 hours. If they fail to, the test must be repeated.
What nursing action is most appropriate when administering both types of oral medication to this client?
- A. Administer the cough syrup first, then the tablets.
- B. Wait 15 minutes after giving the cough syrup before giving the tablets.
- C. Give the cough syrup between administering the tablets.
- D. Administer the tablets first, then the cough syrup.
Correct Answer: D
Rationale: Administering tablets first ensures they are swallowed properly, followed by the cough syrup, which may coat the throat and aid swallowing.
When the client undergoes scratch skin testing, which sign best indicates a hypersensitivity to the scratched substance?
- A. The skin at the test site feels numb.
- B. The skin at the test site feels painful.
- C. The skin at the test site looks red.
Correct Answer: C
Rationale: A positive skin test reaction is indicated by redness and swelling at the test site, showing a hypersensitivity response to the allergen.