Dalteparin (Fragmin) has been ordered for a client with pulmonary embolis. Which statement made by the graduate nurse indicates inadequate understanding of the medication?
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Solution
Answer C is correct. It is necessary to check the PTT as well as administer in the abdomen, as stated in answer C. It is not necessary to administer this medication before meals; thus, answer A is incorrect. Answer D is incorrect because the nurse should not aspirate after the injection.
The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:
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Solution
Answer C is correct. If the finger cannot be used, the next best place to apply the oxygen monitor is to the earlobe. It can also be placed on the forehead, but the choices in answers A, B, and D are incorrect.
While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to:
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Solution
Answer A is correct. The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea. The next action after obtaining these vital signs is to notify the doctor for additional orders. Rechecking the vitals signs, as in answer B, is wasting time. It is the doctor’s call to order arterial blood gases and an ECG.
The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid:
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Solution
Answer C is correct. The client with a femoral popliteal bypass graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Resting in a supine position, resting in a recliner, or sleeping in right Sim’s are allowed, as stated in answers A, B, and D.
The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows that the proper method of applying the stockings is:
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Solution
Answer A is correct. The best time to apply antithrombolytic stockings is in the morning before rising. If the doctor orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are incorrect because there is likely to be more peripheral edema if the client is standing or has just taken a bath; before retiring in the evening is wrong because, late in the evening, more peripheral edema will be present.
The nurse has just received shift report and is preparing to make rounds. Which client should be seen first?
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Solution
Answer C is correct. The client admitted 1 hour ago with shortness of breath should be seen first because this client might require oxygen therapy. The client in answer A with a low-grade temperature can be assessed after the client with shortness of breath. The client in answer B can also be seen later. This client will have some inflammatory process after surgery, so a temperature of 100.2°F is not unusual. The low-grade temperature should be re-evaluated in 1 hour. The client in answer D can be reserved for later.
A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:
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Solution
Answer A is correct. The best roommate for the post-surgical client is the client with hypothyroidism. This client is sleepy and has no infectious process. Answers B, C, and D are incorrect because the client with a diabetic ulcer, ulcerative colitis, or pneumonia can transmit infection to the post-surgical client.
The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
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Solution
Answer C is correct. The client taking an anticoagulant should not take aspirin because it will further thin the blood. He should return to have a Protime drawn for bleeding time, report a rash, and use an electric razor. Therefore, answers A, B, and D are incorrect.
The client returns to the recovery room following repair of an intrathoracic aneurysm. Which finding would require further investigation?
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Solution
Answer B is correct. Because the aorta is clamped during surgery, the blood supply to the kidneys is impaired. This can result in renal damage. A urinary output of 20mL is oliguria. In answer A, the pedal pulses that are thready and regular are within normal limits. For answer C, it is desirable for the client’s blood pressure to be slightly low after surgical repair of an aneurysm. The oxygen saturation of 97% in answer D is within normal limits and, therefore, incorrect.
The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?
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Solution
Answer D is correct. When assisting the client with bowel and bladder training, the least helpful factor is the sexual function. Dietary history, mobility, and fluid intake are important factors; these must be taken into consideration because they relate to constipation, urinary function, and the ability to use the urinal or bedpan. Therefore, answers A, B, and C are incorrect.