Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
A. Keep the client's knees in a flexed position while they are in bed.
Keeping the client's knees in a flexed position, is incorrect because prolonged immobility and knee flexion can increase the risk of VTE by impeding venous return.
B. Massage the client's legs every 4 hr while they are awake.
Massaging the client's legs, is not recommended as it may dislodge a potential clot that has formed, leading to a thromboembolic event.
C. Encourage the client to perform circumduction of the feet.
This exercise can help promote blood circulation and prevent clot formation without exerting excessive pressure on the surgical site.
D. Limit the client's fluid intake to 2,000 mL daily.
Adequate hydration is essential for preventing blood clots; dehydration can lead to hemoconcentration and increased risk of thrombosis.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Med Surg 2023 Proctored Exam. Take the full exam now
Full Explanation
A) Keeping the client's knees in a flexed position, is incorrect because prolonged immobility and knee flexion can increase the risk of VTE by impeding venous return.
B) Massaging the client's legs, is not recommended as it may dislodge a potential clot that has formed, leading to a thromboembolic event.
C) This exercise can help promote blood circulation and prevent clot formation without exerting excessive pressure on the surgical site.
D) Adequate hydration is essential for preventing blood clots; dehydration can lead to hemoconcentration and increased risk of thrombosis.
Similar Questions
A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse. "I am afraid to have this procedure." Which of the following responses should the nurse make?
A. "After this procedure, you will feel much better."
Offering reassurance about the outcome of the procedure may not address the client's specific fears.
B. "Let's discuss your concerns about this procedure."
Encouraging the client to discuss their concerns allows the nurse to address any misconceptions or fears the client may have and provide appropriate information and support.
C. "Are you afraid of needles that will be used during the procedure?"
Assuming the client's fear is related to needles may not be accurate and may not address their specific concerns.
D. "Tell me why you are scared to have this procedure."
Asking the client to explain why they are scared is a good approach, but it may not immediately address their fears or provide the support they need.
Full Explanation
A) Offering reassurance about the outcome of the procedure may not address the client's specific fears.
B) Encouraging the client to discuss their concerns allows the nurse to address any misconceptions or fears the client may have and provide appropriate information and support.
C) Assuming the client's fear is related to needles may not be accurate and may not address their specific concerns.
D) Asking the client to explain why they are scared is a good approach, but it may not immediately address their fears or provide the support they need.
A nurse on the medical-surgical unit is caring for a client who has a seizure disorder.
Which of the following interventions should the nurse include in the plan of care?
A. Pad the upper two side rails of the client's bed.
Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B. Maintain peripheral IV access.
Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C. Teach assistive personnel how to apply restraints.
Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D. Keep a padded tongue blade at the client's bedside.
Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.
E. Keep a padded tongue blade at the client's bedside.
Full Explanation
A) Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B) Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C) Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D) Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.
A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?
A. Distended jugular veins
Distended jugular veins are associated with fluid overload, not dehydration.
B. Pitting, dependent edema
Pitting, dependent edema is also associated with fluid overload, not dehydration.
C. Decreased blood pressure
Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D. Increased blood pressure
Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.
Full Explanation
A) Distended jugular veins are associated with fluid overload, not dehydration.
B) Pitting, dependent edema is also associated with fluid overload, not dehydration.
C) Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D) Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.