The nurse is preparing to discharge a client recovering from a pulmonary embolism (PE). Which topics should the nurse to include in the teaching session? Select all that apply.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Limit the use of over-the-counter medications. This is crucial because many over-the-counter medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), can interfere with anticoagulant therapy prescribed for a client recovering from a pulmonary embolism (PE). By limiting OTC medications, the nurse helps prevent potential drug interactions and complications. Option B) Diet to include green leafy vegetables is not directly related to the discharge teaching for a client with a pulmonary embolism. While a healthy diet is important for overall health, specific dietary recommendations related to PE typically focus on maintaining a consistent intake of foods rich in vitamin K (found in green leafy vegetables) to ensure the effectiveness of anticoagulant therapy. Option C) Symptoms of recurrence is important information for the client to be aware of, but it may not be a priority for discharge teaching. Clients recovering from a pulmonary embolism should be educated about signs and symptoms of recurrence, but this information is usually covered during the acute phase of care rather than at discharge. Option D) Anticoagulant administration schedule is also important information for the client, but it is typically covered in detail before discharge during the hospital stay. While reinforcing this information is valuable, it may not be the priority for discharge teaching when compared to the immediate need to address potential drug interactions with over-the-counter medications. In an educational context, it is important for nurses to prioritize teaching topics based on the immediate needs of the client. By focusing on limiting over-the-counter medications to prevent interactions with anticoagulant therapy, the nurse ensures the safety and effectiveness of the client's treatment regimen, which is crucial for preventing complications and promoting recovery.

Correct Answer: B

Rationale: As individuals age, particularly older women, there tends to be a decrease in facial hair growth. This change is considered a normal part of the aging process and an expected age-related change in the endocrine system. The other options presented, including normal heart tones, thyroid nodules, and an enlarged and firm pituitary gland, are not typically associated with normal aging of the endocrine system.

Correct Answer: C

Rationale: Following surgery, a patient not voiding for 12 hours raises concerns for urinary retention, especially if the patient was catheterized during the surgical procedure. With urinary retention, the bladder can become distended and palpating for bladder distention can help determine if the patient is experiencing this issue. If the bladder is distended, interventions may be needed to address the urinary retention to prevent complications such as urinary tract infection or bladder distention-related discomfort. The other assessment options (percuting for gastric tympany, auscultating for bowel sounds, inspecting for edema of the urethra) are not as relevant in assessing a patient's urinary status post-surgery.

Correct Answer: A

Rationale: In the context of a patient beginning hemodialysis, it is essential to include fluid and protein intake restriction in the plan of care. This is because patients undergoing hemodialysis have impaired kidney function, leading to difficulty in fluid and waste removal. Restricting fluid and protein intake helps in managing fluid overload and maintaining electrolyte balance. Option B, obtaining weight and orthostatic vital signs, is also important for monitoring the patient's fluid status and assessing for potential hypotension, which are common concerns in patients undergoing hemodialysis. Option C, determining urine-specific gravity and pH, is not relevant in a patient beginning hemodialysis as they typically have reduced or no urine output due to kidney dysfunction. Option D, monitoring serum creatinine, BUN, and hematocrit levels, is important for assessing kidney function but may not be as immediate or crucial as fluid and electrolyte management in the initial plan of care for a patient starting hemodialysis. Option E, assessing blood pressure of the extremity where the fistula has been created, is important for evaluating the fistula's patency and blood flow but is not a priority in the immediate care plan for a patient beginning hemodialysis. Educationally, understanding the rationale behind each aspect of care in hemodialysis is crucial for nurses to provide safe and effective care to these patients. By prioritizing interventions based on patient needs and treatment goals, nurses can optimize outcomes and enhance the quality of care provided.

Correct Answer: A

Rationale: In caring for a patient recovering from a below-the-knee amputation, it is crucial to include elevation of the stump in the plan of care. Elevation helps reduce swelling, promotes venous return, and aids in preventing complications such as edema and poor circulation. Keeping the knee extended is not recommended as it can lead to contractures and discomfort. Similarly, applying a knee immobilizer is unnecessary and may hinder the patient's mobility. Avoiding sitting for prolonged periods is important for preventing pressure ulcers but is not directly related to stump care. Providing passive range of motion (ROM) exercises every 2 to 4 hours helps maintain joint flexibility and prevents stiffness in remaining limbs, but it is not specifically targeted at stump care. Educationally, understanding the rationale behind these interventions is essential for nurses to provide effective and evidence-based care for patients undergoing an amputation.