Extract:

Question 1 of 5

A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

A. Apply cold therapy to the affected leg.B. Monitor Homan's sign.C. Obtain a venous duplex ultrasound.D. Obtain impedance plethysmography.

Correct Answer: C

Rationale: Venous duplex ultrasound is the gold standard for diagnosing DVT as it visualizes blood flow and identifies thrombi within the veins, providing accurate and non-invasive detection.

Question 2 of 5

A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site. Which of the following actions should the nurse take?

A. Assess pulses in the client's affected arm.B. Keep the client NPO for at least 2 hours following the procedure.C. Apply light pressure to the insertion site.D. Encourage the client to ambulate within 30 minutes following the procedure.

Correct Answer: A

Rationale: Assessing pulses in the affected arm ensures proper blood flow and identifies potential complications like arterial occlusion following cardiac catheterization.

Question 3 of 5

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?

A. A headache is an expected adverse effect of the medication.B. A headache indicates tolerance to the medication.C. A headache is likely due to anxiety about the chest pain.D. A headache is an indication of an allergy to the medication.

Correct Answer: A

Rationale: Nitroglycerin causes vasodilation, leading to headaches as a common adverse effect. These headaches are due to the increased blood flow and dilation of cerebral blood vessels.

Question 4 of 5

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?

A. My tongue is red and beefy.B. I am constipated.C. My vision seems yellow.D. I am gaining weight.

Correct Answer: C

Rationale: Digoxin toxicity often manifests as visual disturbances, such as yellow or blurred vision, due to its effect on the central nervous system.

Question 5 of 5

A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.)

A. Pregnancy.B. Oral contraceptive use.C. Trauma.D. Immobility.

Correct Answer: A,B,C,D

Rationale: Pregnancy, oral contraceptive use, trauma, and immobility are all risk factors for DVT due to increased venous stasis, hypercoagulability, or vessel injury.