A nurse is assessing a patient who has a history of deep vein thrombosis (DVT). Which of the following findings would be most concerning?

Correct Answer: C

Rationale: The correct answer is C: Shortness of breath and chest pain. This is most concerning because it could indicate a pulmonary embolism, a serious complication of DVT where a blood clot travels to the lungs. Shortness of breath and chest pain are signs of compromised respiratory and cardiac function. A: Pain and swelling in the leg are common symptoms of DVT but not as concerning as symptoms of a pulmonary embolism. B: Redness and warmth around the affected area are typical signs of inflammation associated with DVT but do not indicate a life-threatening complication like a pulmonary embolism. D: Pale skin and decreased pulse in the affected leg could be signs of compromised circulation due to DVT, but they are not as immediately life-threatening as symptoms of a pulmonary embolism.

Correct Answer: C

Rationale: The correct answer is C because the clothing of a trauma client could potentially be considered evidence with legal implications. Preserving the bloodstains or tears on the clothing maintains the integrity of the evidence for forensic investigation or legal proceedings. Disrupting the bloodstains or tears could compromise the evidence and hinder any potential investigation or legal case. Choices A, B, and D are incorrect because the primary concern in this scenario is the legal implications and preservation of evidence, not ownership, repair, salvage, or minimizing trauma to family members.

Correct Answer: A

Rationale: The correct answer is A: Assess vital signs. Vital signs provide crucial information on the client's overall condition and can help identify any life-threatening issues. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can guide immediate interventions and determine the urgency of further assessments or treatments. Administering oxygen (B) would be appropriate after assessing vital signs. Performing an ECG (C) may be indicated later but is not the priority in this acute situation. Monitoring serum glucose levels (D) is not typically the first assessment in a client with severe abdominal pain.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. This is the first step in the care of a client with a severe allergic reaction because epinephrine is the primary medication used to reverse the life-threatening symptoms of anaphylaxis. Epinephrine acts quickly to constrict blood vessels, relax smooth muscles in the lungs to improve breathing, and increase heart rate. Administering epinephrine promptly can prevent progression to severe outcomes like respiratory failure or shock. Corticosteroids (B and C) are used as adjunct therapy and do not provide immediate relief. Applying a cold compress (D) does not address the systemic effects of anaphylaxis and can delay potentially life-saving treatment.

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating sepsis as they help to fight the underlying infection causing the condition. Administering antibiotics promptly can prevent the infection from spreading and worsening. Fluids (choices B and C) are important for treating sepsis to maintain blood pressure and support organ function, but antibiotics are the primary intervention to target the infection. Administering oxygen (choice D) may be necessary to support respiratory function in septic patients, but it is not the most effective action to address the underlying infection.

Correct Answer: D

Rationale: The correct answer is D, administering antiepileptic medications. This is because during an active seizure, the priority is to stop the seizure activity. Antiepileptic medications are specifically designed to prevent or reduce the frequency and intensity of seizures. Placing the client on their side and protecting their head (choice A) is important for safety but does not address stopping the seizure. Loosening clothing and ensuring safety (choice B) is also important but does not directly address the seizure itself. Monitoring airway and giving oxygen (choice C) is crucial but does not actively stop the seizure. Therefore, administering antiepileptic medications is the most appropriate intervention to address the root cause of the seizure.

Correct Answer: A

Rationale: Step 1: Lisinopril is an ACE inhibitor commonly prescribed post-myocardial infarction to reduce strain on the heart and prevent further damage. Step 2: ACE inhibitors like Lisinopril help lower blood pressure and improve heart function. Step 3: By reducing the workload on the heart, Lisinopril can help prevent complications post-MI. Step 4: Acetaminophen (B) is a pain reliever and does not address the cardiovascular issues post-MI. Step 5: Furosemide (C) and Hydrochlorothiazide (D) are diuretics typically used for managing fluid retention, not the primary focus after an MI. Summary: Lisinopril is the correct choice as it helps improve heart function and prevent complications post-MI, unlike the other options which do not directly address the cardiovascular issues associated with MI.

Correct Answer: B

Rationale: The correct answer is B: Monitor INR levels. INR (International Normalized Ratio) is a crucial parameter to monitor for clients on anticoagulant therapy, as it measures the effectiveness of the medication in preventing blood clots. By monitoring INR levels, the nurse can ensure the client is within the therapeutic range to prevent both bleeding and clotting complications. Choice A (Monitor platelet count) is incorrect because anticoagulant therapy does not directly affect platelet count, and monitoring platelets is more relevant for clients on antiplatelet therapy. Choice C (Monitor bleeding) is partially correct, but focusing solely on monitoring bleeding may not provide a comprehensive assessment of the client's response to anticoagulant therapy. Choice D (Monitor renal function) is incorrect as anticoagulant therapy primarily affects coagulation factors and not renal function. Renal function monitoring may be necessary for certain medications but is not a primary consideration for anticoagulant therapy.

Correct Answer: B

Rationale: The correct answer is B: Specific client issues. A focused assessment is a targeted examination that addresses specific client concerns or issues. By focusing on a particular aspect of the client's health, healthcare providers can gather relevant information efficiently and effectively. This approach allows for a more in-depth evaluation of the specific problem at hand, leading to better treatment outcomes. Choice A (Comprehensive physical findings) is incorrect because a focused assessment does not aim to gather information on all physical findings, but rather on specific issues. Choice C (Multiple body systems) is incorrect because a focused assessment is more narrow in scope and typically focuses on one area or system of the body. Choice D (Long-term wellness goals) is incorrect as a focused assessment is more immediate and targeted towards addressing current issues rather than long-term goals.