A nurse is reinforcing teaching about the prevention of deep vein thrombosis (DVT) with a group of newly licensed nurses. Which of the following interventions should the nurse include in the teaching?

Limit movement of the lower extremities.

Place sequential compression devices bilaterally.

Massage lower extremities daily.

Check for negative Homans' sign.

Answer and Explanation

The Correct Answer is B

A. Limit movement of the lower extremities. Limiting movement increases the risk of venous stasis, which can lead to DVT. Regular movement and ambulation are encouraged to promote blood circulation.

B. Place sequential compression devices bilaterally. Sequential compression devices (SCDs) help promote venous return and prevent venous stasis, thereby reducing the risk of DVT.

C. Massage lower extremities daily. Massaging the legs is contraindicated in clients at risk for DVT because it can dislodge a clot and lead to pulmonary embolism.

D. Check for negative Homans' sign. The Homans' sign (pain in the calf on dorsiflexion of the foot) is not a reliable indicator of DVT and is no longer recommended as a standard assessment method.

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Correct Answer is C

Explanation

A. Obtain a blood sample. While obtaining a blood sample to check cardiac enzyme levels is important for diagnosing myocardial injury, it is not the priority over oxygen therapy, given the client’s shortness of breath and cyanosis.

B. Insert the IV catheter. IV access is important for administering fluids and medications, but it is not the first priority in this scenario where the client is experiencing respiratory distress.

C. Initiate oxygen therapy. The client shows signs of hypoxia (shortness of breath and cyanosis), and oxygen is crucial for stabilizing oxygen levels and preventing further deterioration of cardiac and respiratory function.

D. Attach the leads for a 12-lead ECG. Attaching the leads for an ECG is essential to evaluate the client's cardiac status, but it is not the most urgent action in the presence of cyanosis and respiratory distress.

A. "Why have you changed your mind about the surgery?" B. "Your provider would not have scheduled the surgery unless you needed it." C. "I will call your doctor and have him discuss your surgery with you." D. "Bypass surgery must be very frightening for you."

Correct Answer is D

Explanation

A. "Why have you changed your mind about the surgery?" Asking "why" may sound accusatory and could cause the client to feel defensive. It's more effective to use therapeutic communication techniques that encourage open expression of feelings.

B. "Your provider would not have scheduled the surgery unless you needed it."This response minimizes the client's concerns and implies that their feelings are not valid, which can hinder communication.

C. "I will call your doctor and have him discuss your surgery with you." While involving the provider is important, this response deflects the client's concerns without first addressing their feelings or providing support.

D. "Bypass surgery must be very frightening for you." This response uses a therapeutic communication technique by acknowledging the client’s emotions and opening the conversation for further exploration of their concerns.

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A nurse is reinforcing teaching about the prevention of deep vein thrombosis (DVT) with a group of newly licensed nurses. Which of the following interventions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

A nurse is caring for a patient who has a suspected myocardial infarction. Which of the following should the nurse administer first?

A nurse is reviewing the prescriptions for a newly admitted client who is to undergo cardiac testing. For which of the following procedures should the nurse verify that the client has given written informed consent?

A nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider?

A nurse is preparing to administer amoxicillin 500 mg PO. Available is amoxicillin 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

. A nurse is preparing to administer lactated Ringer's solution IV to infuse at 120 mL/hr for a client who has a respiratory disorder. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)