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1. A healthcare provider is caring for a client with a pressure ulcer and needs to review the client's medical history. Which of the following findings is expected?
- A. A Braden scale score of 20
- B. An albumin level of 3 g/dL
- C. A hemoglobin level of 13 g/dL
- D. A Norton scale score of 18
Correct answer: B
Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, a common factor in the development of pressure ulcers. The Braden scale assesses the risk of developing pressure ulcers but does not reflect the client's medical history. Hemoglobin level is more related to oxygen-carrying capacity rather than pressure ulcer development. The Norton scale evaluates risk for developing pressure ulcers but is not typically part of a client's medical history.
2. How should a healthcare professional assess a patient with suspected deep vein thrombosis (DVT)?
- A. Monitor for leg pain, swelling, and redness
- B. Check for calf tenderness and administer anticoagulants
- C. Check for discoloration and monitor oxygen saturation
- D. Check for numbness and provide thrombolytic therapy
Correct answer: A
Rationale: Correct Answer: The correct way to assess a patient with suspected deep vein thrombosis (DVT) is to monitor for leg pain, swelling, and redness. These are common clinical manifestations of DVT. Choice B is incorrect because administering anticoagulants should be based on a confirmed diagnosis, not just suspicion. Choice C is incorrect because discoloration and oxygen saturation are not primary indicators of DVT. Choice D is incorrect because numbness is not a typical symptom of DVT, and thrombolytic therapy is not the first-line treatment for suspected DVT.
3. What are the key interventions for managing a patient with asthma?
- A. Administer bronchodilators and monitor oxygen levels
- B. Encourage deep breathing exercises
- C. Provide corticosteroids and monitor for respiratory distress
- D. Provide antihistamines and monitor blood pressure
Correct answer: A
Rationale: The correct answer is A: Administer bronchodilators and monitor oxygen levels. Asthma management involves using bronchodilators to help open the airways and improve breathing. Monitoring oxygen levels is essential to ensure the patient is getting enough oxygen. Choice B, encouraging deep breathing exercises, can be helpful for some respiratory conditions but is not a key intervention for managing an acute asthma attack. Choice C, providing corticosteroids and monitoring for respiratory distress, is important for long-term asthma management and severe exacerbations but is not the immediate key intervention during an acute attack. Choice D, providing antihistamines and monitoring blood pressure, is not typically indicated for asthma management as asthma is primarily an airway disease, not a histamine-mediated condition.
4. A nurse is caring for a client who has a chest tube following a thoracotomy. Which of the following findings should the nurse report to the provider?
- A. Drainage of 75 mL in the first hour after surgery.
- B. Constant bubbling in the water seal chamber.
- C. Tidaling in the water seal chamber.
- D. Client report of pain at the chest tube insertion site.
Correct answer: B
Rationale: Constant bubbling in the water seal chamber indicates an air leak, which should be reported to the provider. This finding suggests that the chest tube system is not functioning properly, leading to potential complications such as pneumothorax. Drainage of 75 mL in the first hour after surgery is within the expected range for a chest tube. Tidaling in the water seal chamber is a normal fluctuation and indicates proper functioning of the system. Client report of pain at the chest tube insertion site is expected after surgery and can be managed with appropriate pain management measures.
5. A nurse is teaching a client who is taking warfarin about food and medication interactions. Which of the following foods should the nurse instruct the client to avoid?
- A. Tomatoes
- B. Apples
- C. Broccoli
- D. Green leafy vegetables
Correct answer: D
Rationale: Correct Answer: Green leafy vegetables - Green leafy vegetables are high in vitamin K, which can interfere with the effectiveness of warfarin. Tomatoes, apples, and broccoli are not contraindicated with warfarin therapy. While they are healthy choices, they do not have a significant impact on warfarin's effectiveness.
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