A pregnant client's leg is swollen and painful. What action by the nurse is best?

Correct Answer: D

Rationale: The correct answer to the question is option D: Prepare to teach about heparin sodium. This is the best action by the nurse in this scenario because swelling and pain in a pregnant client's leg can be indicative of deep vein thrombosis (DVT), which is a common condition during pregnancy. Heparin sodium is the standard treatment for DVT as it helps prevent the formation of blood clots. Option A: Assess the client's ankle-brachial index is incorrect because in this case, the priority is to address the potential DVT rather than assessing for arterial insufficiency. Option B: Elevate the client's leg above the heart is incorrect because while elevation can help with swelling in some cases, it is not the appropriate intervention for suspected DVT. Prompt treatment with anticoagulants like heparin is crucial. Option C: Obtain an ice pack to provide comfort is incorrect because applying ice packs may provide temporary relief for musculoskeletal injuries but is not the appropriate intervention for a suspected DVT. Educationally, it is important for nurses to understand the signs and symptoms of DVT, especially in high-risk populations like pregnant women. Recognizing these symptoms early and initiating appropriate treatment, such as anticoagulation therapy with heparin, can prevent serious complications like pulmonary embolism. Nurses should be knowledgeable about evidence-based practices for the management of DVT to provide safe and effective care to their patients.

Correct Answer: C

Rationale: The correct answer is C: "When inhaling two different medications, I should use the bronchodilator last." This statement is incorrect because when using multiple inhalers, the bronchodilator should be used first to open up the airways, making it easier for the other medications to reach the lungs effectively. This indicates a need for further teaching because the client has misunderstood the correct order of inhaler use, which could impact the effectiveness of their asthma management. Option A: "I need to rinse my mouth after every use of my inhaler" is correct as rinsing the mouth after using an inhaler helps prevent oral thrush, a common side effect of inhaled corticosteroids. Option B: "I need to take my Singulair at least 1 hour before I eat" is correct because taking Singulair on an empty stomach helps with optimal absorption. Option D: "Because I am on theophylline, I will need to have therapeutic blood levels drawn" is correct as theophylline levels need to be monitored to ensure they are within the therapeutic range and to prevent toxicity. Educationally, this question highlights the importance of proper inhaler technique and medication administration in asthma management. It emphasizes the critical role of nurses in providing accurate and clear education to clients to promote optimal health outcomes. Understanding the correct order of inhaler use is essential for clients with asthma to maximize the effectiveness of their medications and improve their quality of life.

Correct Answer: C

Rationale: In this scenario, the most appropriate nursing diagnosis for an infant with acute bronchiolitis due to RSV would be "Activity Intolerance" (C). This choice is correct because infants with RSV bronchiolitis often experience fatigue and decreased energy levels due to increased respiratory effort and compromised lung function. Activity Intolerance reflects the infant's reduced capacity to engage in physical activity due to the respiratory distress caused by the bronchiolitis. Option A, Acute Pain, is incorrect because the primary concern in this case is not pain but rather the infant's ability to tolerate activity. Option B, Ineffective Tissue Perfusion, is not the most appropriate choice as there is no indication in the question stem that tissue perfusion is the primary issue for the infant. Option D, Decreased Cardiac Output, is also not the best choice as the main focus here is on the infant's respiratory status rather than cardiac function. Educationally, this question helps students understand the importance of accurately assessing and diagnosing respiratory conditions in pediatric patients. It emphasizes the need to differentiate between various nursing diagnoses based on the specific symptoms and underlying pathophysiology of the condition. By selecting the correct nursing diagnosis, students learn to provide targeted and effective care to meet the individualized needs of infants with respiratory illnesses like RSV bronchiolitis.

Correct Answer: C

Rationale: In this scenario, option C, which is to educate the patient and family regarding the safe use of oxygen therapy equipment, is the most appropriate initial action to minimize the risk of injury related to oxygen therapy in the patient's home. Educational Rationale: 1. **Correct Answer Explanation (Option C):** Providing comprehensive education on the safe use of oxygen therapy equipment is crucial as it covers all potential risks associated with oxygen therapy, including combustibility and smoking hazards. By educating the patient and their family, the nurse empowers them to understand the importance of safe practices, such as ensuring proper ventilation, avoiding smoking near oxygen sources, and knowing emergency procedures. This knowledge equips them to manage oxygen therapy effectively and prevent potential accidents. 2. **Explanation of Incorrect Options:** - Option A: While it is important to inform the patient that oxygen is combustible, this information alone does not address the comprehensive education needed for safe oxygen therapy management. - Option B: Warning the patient not to smoke in the presence of oxygen therapy equipment is essential, but it is only one aspect of safe oxygen therapy practices. Education should cover a wider range of safety measures. - Option D: Arranging for oxygen therapy equipment delivery is important but does not address the immediate need for educating the patient and family on safe usage practices. 3. **Educational Context:** Education plays a pivotal role in empowering patients to actively participate in their care and ensure safety. By providing thorough education on oxygen therapy safety, nurses enable patients and families to make informed decisions, recognize potential risks, and respond effectively in case of emergencies. This proactive approach enhances patient outcomes and reduces the likelihood of injuries related to oxygen therapy at home. In conclusion, option C is the best initial step as it focuses on empowering the patient and family through education, which is fundamental in ensuring the safe administration and management of oxygen therapy in the home setting.

Correct Answer: B

Rationale: In the context of nursing fundamentals and the topic of oxygenation, understanding the distribution of freshwater on Earth is crucial as it directly impacts the availability of clean water for patients' hydration and respiratory care. The correct answer, option B (3 per cent of the water on earth), is accurate because freshwater constitutes only a small percentage of the total water on Earth, with the majority being saltwater. This knowledge is essential for nurses as they need to be aware of the limited freshwater sources for patient care and health promotion. Option A (97 per cent of the water on earth) is incorrect because this percentage represents saltwater, not freshwater. Nurses must understand this distinction to address patients' hydration needs properly. Option C (0.04 per cent in air) is incorrect as it refers to the percentage of water vapor in the atmosphere, not freshwater. Option D (21 per cent in air) is also inaccurate as it represents the percentage of oxygen in the atmosphere, not freshwater content. Educationally, this question serves to reinforce the importance of accurate knowledge in understanding basic environmental science concepts for nursing practice. By grasping the distribution of freshwater, nurses can appreciate the significance of water conservation, patient education on hydration, and the role of water in maintaining optimal oxygenation levels in the body. This foundational knowledge underlines the interconnectedness of environmental factors with patient health and the nurse's role in promoting holistic care.