A client receiving heparin therapy for deep venous thrombosis (DVT) complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, which is the priority action by the nurse?

Correct Answer: A

Rationale: The priority action by the nurse when a client receiving heparin therapy for deep venous thrombosis (DVT) presents with symptoms suggestive of a pulmonary embolism, such as severe chest pain and shortness of breath, is to assess the client's pulse, respirations, and blood pressure. These vital signs will provide crucial information about the client's current cardiovascular and respiratory status, which is essential for determining the severity of the condition and guiding immediate interventions. Assessing these vital signs will help the nurse quickly identify any signs of hemodynamic instability or respiratory distress, enabling prompt and appropriate treatment to be initiated. Once the assessment is done, further interventions such as oxygen therapy and notifying the healthcare provider can be implemented as needed.

Correct Answer: D

Rationale: Tobacco use is a modifiable risk factor for hypertension. Smoking cigarettes can lead to an increase in blood pressure and heart rate, as well as damage to blood vessels, which can contribute to the development of hypertension. By quitting smoking or avoiding tobacco use, individuals can reduce their risk of developing hypertension and improve their overall cardiovascular health. On the other hand, factors such as age, ethnicity, and family history are non-modifiable risk factors for hypertension, meaning individuals cannot change them through lifestyle modifications.

Correct Answer: B

Rationale: The nursing diagnosis of Activity Intolerance is the most appropriate for a client with a cardiac dysrhythmia who reports being easily fatigued and having difficulty performing normal daily activities. Cardiac dysrhythmias can lead to decreased cardiac output, which can result in reduced oxygen delivery to the body's tissues, contributing to fatigue and weakness. Activity Intolerance is defined as the state in which an individual experiences or is at risk of experiencing insufficient physiological or psychological energy to endure or complete daily activities. This diagnosis is fitting for the client's inability to perform normal daily activities due to the cardiac dysrhythmia-induced fatigue and weakness. Addressing Activity Intolerance will involve collaborating with the client to set achievable activity goals and incorporating periods of rest to enhance tolerance to physical activity and improve overall function.

Correct Answer: D

Rationale: An Unna boot is a type of compression bandage that is impregnated with zinc oxide paste. This paste helps to provide a moist environment for the wound, which can promote healing and also has antimicrobial properties. The compression from the Unna boot helps to reduce swelling and improve circulation in the affected area, which is beneficial for treating stasis ulcers. By understanding that an Unna boot contains zinc oxide paste, the home care nurse can ensure proper application and effectiveness in promoting wound healing.

Correct Answer: D

Rationale: The priority nursing diagnosis for a client admitted with a gunshot wound to the femoral artery is Decreased Cardiac Output. The femoral artery is a major blood vessel that supplies oxygenated blood to the lower extremities. A gunshot wound to this artery can lead to severe blood loss, causing a decrease in cardiac output. Decreased cardiac output can result in inadequate perfusion to vital organs, potentially leading to shock and organ failure. Therefore, monitoring and addressing the client's cardiac output is the priority to ensure adequate tissue perfusion and prevent further complications. Deficient Fluid Volume may be related to the blood loss but addressing cardiac output is more critical in this situation.