Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?
A. Apply cold compresses.
Applying cold compresses is not indicated for pain and redness of the calf, which mayindicate deep vein thrombosis (DVT). Cold therapy is not recommended as it can worsen the condition.
B. Massage the area.
Massaging the area is contraindicated in suspected DVT as it can dislodge a clot and lead to complications such as pulmonary embolism.
C. Elevate her leg.
Elevating her leg helps to reduce swelling and improve venous return, which can alleviate symptoms of DVT and prevent further complications.
D. Flex her knee while resting.
Flexing her knee while resting is not specifically indicated for the management of suspected DVT and may not address the underlying cause of pain and redness in the calf.
This question is an excerpt from Nurse Dive's nursing test bank - Ati N230 Exam 3 With Ngn Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
A. Applying cold compresses is not indicated for pain and redness of the calf, which may
indicate deep vein thrombosis (DVT). Cold therapy is not recommended as it can worsen the condition.
B. Massaging the area is contraindicated in suspected DVT as it can dislodge a clot and lead to complications such as pulmonary embolism.
C. Elevating her leg helps to reduce swelling and improve venous return, which can alleviate symptoms of DVT and prevent further complications.
D. Flexing her knee while resting is not specifically indicated for the management of suspected DVT and may not address the underlying cause of pain and redness in the calf.
Similar Questions
A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?
A. Encourage the client to move to the left lateral position.
Encouraging the client to move to the left lateral position helps to promote uterinecontractions and reposition the uterus to its midline position, which can help to alleviate uterine atony.
B. Assist the client to the bathroom to void.
Assisting the client to the bathroom to void may be appropriate to relieve bladder distention, but it does not directly address the issue of uterine atony.
C. Ask the client to rate her pain.
Asking the client to rate her pain is not relevant to the assessment findings of a slightly boggy and displaced fundus.
D. Encourage the client to perform Kegel exercises.
Encouraging the client to perform Kegel exercises is not indicated for the management of uterine atony.
Full Explanation
A. Encouraging the client to move to the left lateral position helps to promote uterine
contractions and reposition the uterus to its midline position, which can help to alleviate uterine atony.
B. Assisting the client to the bathroom to void may be appropriate to relieve bladder distention, but it does not directly address the issue of uterine atony.
C. Asking the client to rate her pain is not relevant to the assessment findings of a slightly boggy and displaced fundus.
D. Encouraging the client to perform Kegel exercises is not indicated for the management of uterine atony.
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
A. Monitor the newborn's blood pressure.
Monitoring the newborn's blood pressure may be indicated in some situations but is not the priority in this case, as the symptoms described suggest hypoglycemia rather than hypertension.
B. Obtain blood glucose by heel stick.
Obtaining blood glucose by heel stick is the priority action. The symptoms of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia in newborns, and obtaining a blood glucose level will confirm the diagnosis and guide appropriate treatment.
C. Place the newborn in a radiant warmer.
Placing the newborn in a radiant warmer may help to prevent heat loss but does not address the underlying issue of hypoglycemia.
D. Initiate phototherapy.
Initiating phototherapy is not indicated for the symptoms described, which suggest hypoglycemia rather than hyperbilirubinemia.
Full Explanation
A. Monitoring the newborn's blood pressure may be indicated in some situations but is not the priority in this case, as the symptoms described suggest hypoglycemia rather than hypertension.
B. Obtaining blood glucose by heel stick is the priority action. The symptoms of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia in newborns, and obtaining a blood glucose level will confirm the diagnosis and guide appropriate treatment.
C. Placing the newborn in a radiant warmer may help to prevent heat loss but does not address the underlying issue of hypoglycemia.
D. Initiating phototherapy is not indicated for the symptoms described, which suggest hypoglycemia rather than hyperbilirubinemia.
A nurse is planning care for a newborn who has spina bifida. Which of the following actions should be included in the plan of care?
A. Apply snug, clean diapers.
Applying snug diapers is not recommended as it can put pressure on the sacral lesion, potentially causing damage or infection.
B. Obtain rectal temperatures.
Obtaining rectal temperatures is contraindicated due to the risk of bowel and nerve damage.
C. Place the newborn in the prone position.
Placing the newborn in the prone position is the correct action, as it prevents pressure on the lesion and reduces the risk of trauma or infection.
D. Cover the lesion with a dry dressing.
Covering the lesion with a dry dressing is incorrect. The lesion should be covered with a moist, sterile, non-adherent dressing to prevent drying out and minimize infection risk.
Full Explanation
A. Applying snug diapers is not recommended as it can put pressure on the sacral lesion, potentially causing damage or infection.
B. Obtaining rectal temperatures is contraindicated due to the risk of bowel and nerve damage.
C. Placing the newborn in the prone position is the correct action, as it prevents pressure on the lesion and reduces the risk of trauma or infection.
D. Covering the lesion with a dry dressing is incorrect. The lesion should be covered with a moist, sterile, non-adherent dressing to prevent drying out and minimize infection risk.