NR 304 Exam 1 questions and answer with detailed rationales

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?

Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level.

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism. The nurse should instruct the client to avoid which of the following unsafe actions?

Massaging her legs

A nurse on the med-surg unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for developing deep vein thrombosis.

Hip arthroplasty

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?

Obtain a venous duplex ultrasound

A nurse is providing discharge teaching to a client who has peripheral arterial disease. Which of the following instructions should the nurse include in the teaching.

Adjust the thermostat so the environment is warm

A nurse is caring for a client who has peripheral arterial disease. Which of the following symptoms should the nurse expect to find in the early stage of the disease?

Intermittent claudication

A nurse is providing postoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear anti-embolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

They improve circulation to keep you blood from pooling in your legs

A nursing is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify which of the following results places the client at risk.

LDL 172 mg/dL

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?

The client will walk for 30 min a day 5 days a week

A nurse is reviewing the lab results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet?

I eat two eggs for breakfast each morning

A nurse is administering morphine 2 mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects?

Orthostatic hypotension

A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV blous every 6 hr as needed. Before administering the medication, the nurse should complete which priority assessment?

Respiratory rate

A nurse is assessing four female clients for obesity. Which of the following clients have manifestations of obesity?

A client who weighs 28% above ideal body weight

A nurse is providing post operative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in the teaching.

Instruct the client about the use of a sequential compression device

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Increase dietary intake of raw vegetables

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation?

Excessive laxative use

Ignoring the urge to defecate

Inadequate fluid intake