a nurse is assessing a client who has deep vein thrombosis dvt which of the following findings should the nurse expect
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LPN Fundamentals of Nursing

1. A healthcare professional is assessing a client who has deep-vein thrombosis (DVT). Which of the following findings should the professional expect?

Correct answer: D

Rationale: Redness and warmth of the affected limb are classic signs of deep-vein thrombosis (DVT) due to inflammation and increased blood flow. These symptoms occur as a result of the blood clot obstructing normal blood flow and causing localized inflammation in the affected limb. Swelling of the affected limb, diminished peripheral pulses, and coolness are not typically associated with DVT. Swelling can be present but is often accompanied by the characteristic redness and warmth. Diminished pulses and coolness are more indicative of arterial insufficiency rather than venous thrombosis.

2. What is the primary goal of palliative care?

Correct answer: C

Rationale: The primary goal of palliative care is to provide comfort and improve the quality of life for clients with serious illnesses. Palliative care aims to address physical, emotional, and spiritual needs to enhance overall well-being rather than focusing on curing the underlying illness, prolonging life, or preparing for surgery. It emphasizes symptom management, pain relief, and support for patients and their families to ensure a better quality of life during the course of their illness.

3. A client has a new prescription for a low-sodium diet. Which of the following foods should the nurse recommend?

Correct answer: C

Rationale: Fresh fruits are naturally low in sodium, making them a suitable choice for a low-sodium diet. They provide essential nutrients and are a healthy option for individuals who need to limit their sodium intake. Pickles (Choice A) and canned soup (Choice B) are typically high in sodium and should be avoided in a low-sodium diet. Smoked salmon (Choice D) is also usually high in sodium due to the smoking process, so it is not a recommended choice for a low-sodium diet.

4. During discharge instructions, a client with a new prescription for a metered-dose inhaler (MDI) states, 'I will shake the inhaler before each use.' Which of the following client statements indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A because shaking the inhaler before each use ensures that the medication is properly mixed, which is essential for effective administration. This action helps to disperse the medication evenly, enhancing its efficacy when inhaled. Proper mixing through shaking prevents inconsistent dosing and ensures that the client receives the correct amount of medication with each use.

5. In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?

Correct answer: B

Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.

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