Nokea
You're developing a plan of care for a patient who is at risk for the development of a deep vein thrombosis after surgery. What nursing intervention below would the nurse NOT include in the patient's plan of care to prevent DVT formation?
- A. The patient will eat all meals out of the bed daily by sitting in the bedside chair.
- B. The nurse will apply sequential compression devices (SCDs) per physician's order to the patient's lower extremities every night at bedtime.
- C. The nurse will administer per physician's order Enoxaparin in the subcutaneous tissue of the abdomen.
- D. The patient will ambulate daily.
Correct Answer: B
Rationale: Yes, the nurse would apply SCDs per MD order to help prevent DVTs, BUT they are to be applied and worn by the patient anytime they are in bed or sitting. The only time a patient should not wear the SCDs is when they're ambulating. Therefore, the nurse would NOT just apply them at bedtime but during the day too.
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If the client identifies that lunches often include the following foods, which meal is the most nutritious?
- A. Tossed salad, rice, and iced tea
- B. Apple sandwich on whole wheat bread and coffee
- C. Meatless chili with beans, corn bread, and milk
- D. Chicken soup, gelatin, and sweetened lemonade
Correct Answer: C
Rationale: Meatless chili with beans, corn bread, and milk provides protein, carbohydrates, and calcium, making it the most balanced and nutritious option.
The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement?
- A. Assess the client for abnormal bleeding.
- B. Prepare to administer vitamin K (AquaMephyton).
- C. Administer the medication as ordered.
- D. Notify the HCP to obtain an order to increase the dose.
Correct Answer: C
Rationale: INR 2.8 (C) is therapeutic for PE (2–3), so administer warfarin. Bleeding assessment (A) is routine, vitamin K (B) reverses overdose, and increasing dose (D) is unnecessary.
The nurse is caring for the client diagnosed with bacterial pneumonia. Which priority intervention should the nurse implement?
- A. Assess respiratory rate and depth.
- B. Provide for adequate rest period.
- C. Administer oxygen as prescribed.
- D. Teach slow abdominal breathing.
Correct Answer: C
Rationale: Administering oxygen as prescribed (C) is the priority for bacterial pneumonia to address hypoxemia, a common issue due to impaired gas exchange. Assessing respiratory rate (A) is important but secondary to ensuring oxygenation. Rest (B) and breathing techniques (D) support recovery but are not the first priority.
Which statement by the client best indicates that the client understands the rationale for the direct laryngoscopy?
- A. The test will tell if my hoarseness is caused by tracheal polyps.
- B. The physician says that hoarseness can lead to bronchitis.
- C. I need to have the test because hoarseness is a symptom of laryngeal cancer.
- D. The physician wants to see if my hoarseness is because of enlarged tonsils.
Correct Answer: C
Rationale: Persistent hoarseness can be a symptom of laryngeal cancer, and direct laryngoscopy is used to visualize the larynx for abnormalities like tumors.
Because of the client's pleural effusion and advanced lung disease, what would the nurse expect to hear when assessing the breath sounds?
- A. Wheezing in the upper lobes
- B. A friction rub posterior to the affected area
- C. Crackles over the affected area
- D. Decreased sounds over the involved area
Correct Answer: D
Rationale: Pleural effusion causes decreased breath sounds over the affected area due to fluid accumulation compressing the lung.