The nurse is providing teaching about long-term anticoagulant therapy to a client recovering from a pulmonary embolism. Which client statement indicates that instruction has been effective?

Questions 14

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Fundamental Concepts and Skills for Nursing 6th Edition Test Bank Questions

Question 1 of 9

The nurse is providing teaching about long-term anticoagulant therapy to a client recovering from a pulmonary embolism. Which client statement indicates that instruction has been effective?

Correct Answer: B

Rationale: The correct answer is B. The statement "I need to use a soft toothbrush and an electric razor to avoid injuries" indicates that the client understands the importance of preventive measures to minimize bleeding risks while on anticoagulant therapy. Using a soft toothbrush and an electric razor can help prevent accidental cuts that may lead to bleeding complications. It shows the client's understanding of the need to take precautions to avoid potential harm while on long-term anticoagulant therapy. The other statements do not directly address safety measures to prevent bleeding complications associated with anticoagulant therapy.

Question 2 of 9

The nurse is preparing a patient for an intravenous pyelogram. What should be a part of the patient’s care at this time? Select all that apply.

Correct Answer: A

Rationale: A. Assess for allergies to seafood or iodine: It is essential to assess the patient for allergies to seafood or iodine because contrast material containing iodine is commonly used during an intravenous pyelogram (IVP). Allergic reactions to iodine can range from mild to severe, so assessing for allergies is crucial for patient safety.

Question 3 of 9

The nurse is providing teaching about long-term anticoagulant therapy to a client recovering from a pulmonary embolism. Which client statement indicates that instruction has been effective?

Correct Answer: B

Rationale: The correct answer is B. The statement "I need to use a soft toothbrush and an electric razor to avoid injuries" indicates that the client understands the importance of preventive measures to minimize bleeding risks while on anticoagulant therapy. Using a soft toothbrush and an electric razor can help prevent accidental cuts that may lead to bleeding complications. It shows the client's understanding of the need to take precautions to avoid potential harm while on long-term anticoagulant therapy. The other statements do not directly address safety measures to prevent bleeding complications associated with anticoagulant therapy.

Question 4 of 9

The nurse is caring for a patient with a deep venous thrombosis of the left lower extremity. What additional body system should the nurse carefully monitor in this patient?

Correct Answer: C

Rationale: Patients with deep venous thrombosis (DVT) are at risk for developing a complication known as pulmonary embolism, which is a potentially life-threatening condition. A pulmonary embolism occurs when a blood clot dislodges from the veins, typically in the legs, and travels to the lungs, blocking blood flow. This can lead to respiratory symptoms such as shortness of breath, chest pain, and in severe cases, respiratory failure. Therefore, it is essential for the nurse to carefully monitor the respiratory system in a patient with DVT to promptly identify any signs of pulmonary embolism and initiate appropriate interventions to prevent further complications.

Question 5 of 9

The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with preeclampsia. Which statement indicates that the client requires additional teaching?

Correct Answer: A

Rationale: This statement indicates a need for additional teaching because in a client with preeclampsia, dark and reduced urine output could be a sign of kidney involvement and impaired kidney function. In preeclampsia, monitoring urine output, particularly for signs of proteinuria, is crucial as it can indicate worsening of the condition and potential damage to the kidneys. Therefore, the client should be educated that changes in urine color and amount should be reported to the healthcare provider promptly.

Question 6 of 9

Which dysrhythmia is most commonly associated with sudden cardiac death (SCD)?

Correct Answer: B

Rationale: Ventricular fibrillation is the dysrhythmia most commonly associated with sudden cardiac death (SCD). Ventricular fibrillation is a rapid, chaotic, and disorganized electrical activity in the ventricles that leads to ineffective contraction. This dysrhythmia can quickly progress to hemodynamic collapse and ultimately cardiac arrest, resulting in sudden cardiac death if not promptly treated with defibrillation. Atrial flutter, paroxysmal supraventricular tachycardia, and junctional escape rhythm are not typically associated with as high a risk of sudden cardiac death as ventricular fibrillation.

Question 7 of 9

The nurse notes that the patient has a low calcium level and plans to assess for Chvostek’s sign. How will the nurse conduct this assessment?

Correct Answer: C

Rationale: Chvostek’s sign is an assessment technique used to detect hypocalcemia. The nurse will tap lightly over the facial nerve, just in front of the patient’s ear. A positive Chvostek’s sign is indicated by a twitching of the facial muscles on the same side of the face as the area that was tapped. This twitching is due to the hyperexcitability of the facial nerve, which can be a sign of low calcium levels. Therefore, option C is the correct way to conduct the assessment for Chvostek’s sign.

Question 8 of 9

What is the purpose of using warm IV fluids to help resuscitate clients in shock?

Correct Answer: B

Rationale: When a client is in shock, their body is not able to regulate its temperature effectively. In this situation, using warm IV fluids helps prevent hypothermia by providing the body with fluids at a temperature closer to the body's normal core temperature. Hypothermia can worsen the condition of a client in shock by further compromising their body's ability to maintain adequate perfusion and oxygen delivery to tissues. Therefore, utilizing warm IV fluids is essential in the resuscitation of clients in shock to help maintain their core body temperature within a suitable range.

Question 9 of 9

The nurse is caring for a client who has recently received a permanent colostomy. The client will be going home in several days and requires discharge teaching. What should the nurse do when organizing the teaching experience?

Correct Answer: D

Rationale: Breaking the information into small sessions to enhance learning is the most effective approach when organizing the teaching experience for a client with a new permanent colostomy. This allows for better retention of information as the client can focus on a few key points at a time and then progressively build upon that knowledge. By breaking the information into smaller sessions, the nurse can ensure that the client fully understands each aspect of colostomy care before moving on to the next topic. This method promotes better understanding, leads to improved compliance with care instructions, and ultimately contributes to better outcomes for the client.

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