A client who was discharged 3 days ago after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, reddened, and swollen left lower leg. The nurse is preparing to initiate heparin therapy. Which additional intervention should the nurse include in this client's plan of care?

Maintain the client on bedrest.

Administer the client's routine daily aspirin.

Encourage a diet high in iron and ascorbic acid.

Encourage the client to dangle the legs frequently.

Answer and Explanation

The Correct Answer is A

A. Maintain the client on bedrest: The client’s symptoms are consistent with deep vein thrombosis (DVT). Bedrest with limited movement prevents dislodgment of the clot, which could otherwise travel to the lungs and cause a pulmonary embolism. This is the safest initial intervention while anticoagulation is being started.

B. Administer the client's routine daily aspirin: Aspirin has antiplatelet effects but is not the treatment of choice for acute DVT. Starting aspirin with heparin therapy is not recommended, as it increases the risk of bleeding without additional therapeutic benefit.

C. Encourage a diet high in iron and ascorbic acid: While iron and vitamin C support red blood cell production, this dietary intervention does not address the acute management of a thrombus. It may be useful in anemia prevention but is not a priority here.

D. Encourage the client to dangle the legs frequently: Dangling the legs promotes venous stasis and may worsen the clot or increase the risk of embolization. Clients with DVT should avoid activities that increase venous pooling until cleared by the healthcare provider.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Remind the client to keep his appointments to have his cholesterol level checked: Ezetimibe works by reducing absorption of cholesterol in the intestines, which lowers serum lipid levels. The most direct way to evaluate effectiveness is through laboratory testing of cholesterol levels at scheduled follow-up appointments.

B. Assess the elasticity of the client's skin at the next scheduled clinic appointment: Skin elasticity is not affected by cholesterol-lowering therapy and does not provide meaningful information about the effectiveness of ezetimibe.

C. Teach the client to weigh himself weekly and keep a log of the measurements: Weight monitoring is more relevant for managing conditions like heart failure or obesity. Ezetimibe’s primary effect is on lipid levels, not weight change.

D. Encourage the client to keep a diary of his food intake until his next visit to the clinic: While dietary tracking supports lifestyle management, it does not directly measure the pharmacologic effectiveness of ezetimibe. Laboratory results remain the standard for evaluation.

A. Place a warm blanket on the client. B. Administer IV fluids per protocol. C. Review the medication administration record. D. Check the urinary catheter r an occlusion.

Correct Answer is B

Explanation

A. Place a warm blanket on the client: Providing warmth may improve comfort temporarily but does not address the underlying cause of the client’s cool, moist hands, prolonged capillary refill, or low urine output, which suggest possible hypovolemia or shock.

B. Administer IV fluids per protocol: The client’s signs restlessness, cool clammy skin, prolonged capillary refill, and low urine output indicate hypoperfusion likely due to fluid deficit. Administering IV fluids promptly helps restore circulating volume and tissue perfusion.

C. Review the medication administration record: While medication review is important for overall safety, it does not address the immediate risk of hypovolemic shock or low urine output in this client.

D. Check the urinary catheter for an occlusion: Although checking for blockage is reasonable if a catheter is present, the client’s overall clinical presentation points to systemic hypovolemia rather than a localized urinary obstruction.

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Patient Data

Exhibits

For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.

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Naxlex Comprehensive Predictor Exams

To evaluate the effectiveness of a male client's new prescription for ezetimibe, which action should the clinic nurse implement?

Correct Answer is A

Explanation

The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Correct Answer is B

Explanation

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

Patient data Exhibits The nurse considers the brief interaction with the client and the triage report. Which finding(s) should the nurse investigate further? Select all that apply.

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

A client with Parkinson's disease receives a prescription for benztropine. Which common adverse effect(s) should the nurse include in the teaching plan? Select all that apply

Patient Data Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

Patient Data Exhibits For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.