a client with a history of deep vein thrombosis dvt is admitted with unilateral leg swelling which intervention should the nurse implement

HESI RN

Community Health HESI Quizlet

1. A client with a history of deep vein thrombosis (DVT) is admitted with unilateral leg swelling. Which intervention should the nurse implement?

A. Elevate the affected leg on a pillow.
B. Apply a warm compress to the affected leg.
C. Perform passive range-of-motion exercises on the affected leg.
D. Encourage the client to ambulate frequently.

Correct answer: A

Rationale: The correct intervention for a client with a history of deep vein thrombosis (DVT) and unilateral leg swelling is to elevate the affected leg on a pillow. Elevating the affected leg helps reduce swelling and pain by promoting venous return and preventing stasis of blood flow. Applying a warm compress (Choice B) may increase inflammation and worsen the condition. Performing passive range-of-motion exercises (Choice C) and encouraging ambulation (Choice D) can dislodge a clot and lead to potential embolism, making these choices contraindicated in a client with DVT.

2. The nurse is providing discharge teaching to a client with a new diagnosis of diabetes mellitus. Which statement by the client indicates a need for further teaching?

A. I will need to monitor my blood sugar levels daily.
B. I will follow a diet low in carbohydrates.
C. I will rotate the injection sites for my insulin.
D. I will exercise regularly to help manage my diabetes.

Correct answer: B

Rationale: The correct answer is B. The statement 'I will follow a diet low in carbohydrates' indicates a need for further teaching. In diabetes mellitus, it is essential to follow a balanced diet that includes carbohydrates, proteins, and fats. Carbohydrates are a major source of energy and should be included in moderation to help manage blood sugar levels. Monitoring blood sugar levels daily (A), rotating injection sites for insulin (C), and exercising regularly (D) are all appropriate self-management strategies for individuals with diabetes mellitus.

3. A first-grade boy is sent to the school nurse after he fainted while playing tag during recess. When he arrives in the clinic he is alert and oriented and his vital signs include temperature of 97.8Â°F, pulse 96 bpm, respirations 15 breaths/minute, and blood pressure 80/56 mmHg. Which intervention is most important for the nurse to implement?

A. request transport of the child to his pediatrician's office
B. call the child's parents and send him home for the day
C. compare the child's body mass index to normal values
D. measure the child's pulse and blood pressure every 15 minutes

Correct answer: D

Rationale: In this scenario, the most important intervention for the nurse to implement is to measure the child's pulse and blood pressure every 15 minutes. The child experienced a syncopal episode (fainting) which could be due to various reasons, including dehydration or cardiac issues. Monitoring vital signs frequently will help detect any changes that may indicate underlying health issues. Requesting transport to the pediatrician's office or sending the child home without continuous monitoring may not provide immediate assessment and intervention. Comparing the child's body mass index to normal values is not relevant in addressing the immediate concern of monitoring vital signs after a syncopal episode.

4. A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?

A. Pindolol (Visken)
B. Carteolol (Ocupress)
C. Metoprolol tartrate (Lopressor)
D. Propranolol hydrochloride (Inderal)

Correct answer: C

Rationale: The correct answer is C, Metoprolol tartrate (Lopressor). Metoprolol is a beta2 blocking agent that is cardioselective and less likely to cause bronchoconstriction, making it a suitable antihypertensive option for clients with asthma. Choices A, B, and D are non-selective beta-blockers which can potentially exacerbate asthma symptoms by causing bronchoconstriction.

5. During a home health visit, the nurse notices that an older male client with type 2 diabetes mellitus is wearing loose cloth slippers. The client reports that he cannot comfortably wear other shoes because his toenails get in the way. The nurse inspects the client's feet and finds long thick nails that curl down under some of the toes. Which action should the nurse take?

A. demonstrate proper foot care to the client and family
B. have a home health aide assist the client with hygiene weekly
C. schedule an appointment for the client with a podiatrist
D. trim the client's toenails gradually over several visits

Correct answer: C

Rationale: Scheduling an appointment with a podiatrist is the most appropriate action in this scenario. For a client with long thick nails that curl under the toes, professional foot care by a podiatrist is necessary to prevent complications, especially in a client with diabetes mellitus. Demonstrating proper foot care (choice A) may not address the immediate need for nail trimming. Having a home health aide assist with hygiene weekly (choice B) may not be sufficient for managing the client's toenail issue effectively. Trimming the client's toenails gradually over several visits (choice D) should be performed by a professional like a podiatrist to avoid potential complications.