Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
During a postpartum assessment, a woman reports that her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, the nurse explains that the probable treatment will involve:
A. Gentle massage of the affected leg
This is wrong because gentle massage of the affected leg can dislodge the clot and cause a pulmonary embolism.
B. Anticoagulants for 6 weeks
This is because the client’s symptoms suggest that she has deep vein thrombosis (DVT), which is a blood clot in a deep vein of the leg. DVT is a serious condition that can lead to pulmonary embolism, which is a blockage of a blood vessel in the lungs. The treatment for DVT involves anticoagulants, which are drugs that prevent blood clots from growing or forming new ones. The duration of anticoagulant therapy depends on the risk factors and severity of DVT, but it is usually at least 6 weeks.
C. Passive leg exercises twice a day
This is wrong because passive leg exercises can increase blood flow and worsen pain and swelling.
D. Application of ice to the affected leg
This is wrong because the application of ice to the affected leg can reduce inflammation but does not treat the underlying clot.
This question is an excerpt from Nurse Dive's nursing test bank - Postpartum AMD Newborn Care Proctored Exam. Take the full exam now
Full Explanation
Anticoagulants for 6 weeks. This is because the client’s symptoms suggest that she has deep vein thrombosis (DVT), which is a blood clot in a deep vein of the leg. DVT is a serious condition that can lead to pulmonary embolism, which is a blockage of a blood vessel in the lungs. The treatment for DVT involves anticoagulants, which are drugs that prevent blood clots from growing or forming new ones. The duration of anticoagulant therapy depends on the risk factors and severity of DVT, but it is usually at least 6 weeks.
Choice A is wrong because gentle massage of the affected leg can dislodge the clot and cause a pulmonary embolism.
Choice C is wrong because passive leg exercises can increase blood flow and worsen pain and swelling.
Choice D is wrong because the application of ice to the affected leg can reduce inflammation but does not treat the underlying clot.
Similar Questions
The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:
A. Document expected postpartum mucous membrane congestion
This is wrong because postpartum mucous membrane congestion does not cause fever, cough, or shortness of breath.
B. Notify the charge nurse of a possible upper respiratory infection
This is wrong because an upper respiratory infection does not cause edema and redness along the saphenous vein.
C. Notify the physician of a possible pulmonary embolism
This is because the client's symptoms suggest that she has a pulmonary embolism, which is a blockage of a blood vessel in the lungs often caused by blood clots that travel from the legs. Pulmonary embolism is a life-threatening condition that requires immediate medical attention. The client may also have chest pain, coughing up blood, dizziness, or fainting.
D. Medicate with antipyretic remedy for elevated temperature
This is wrong because an antipyretic remedy does not treat the underlying cause of the fever and may mask the severity of the condition.
Full Explanation
Notify the physician of a possible pulmonary embolism. This is because the client's symptoms suggest that she has a pulmonary embolism, which is a blockage of a blood vessel in the lungs often caused by blood clots that travel from the legs. Pulmonary embolism is a life-threatening condition that requires immediate medical attention. The client may also have chest pain, coughing up blood, dizziness, or fainting.
Choice A is wrong because postpartum mucous membrane congestion does not cause fever, cough, or shortness of breath.
Choice B is wrong because an upper respiratory infection does not cause edema and redness along the saphenous vein.
Choice D is wrong because an antipyretic remedy does not treat the underlying cause of the fever and may mask the severity of the condition.
Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. The nurse recognizes that the cause of these signs and symptoms may be:
A. Endometritis
This is because the client's symptoms suggest that she has endometritis, which is an infection of the lining of the uterus. Endometritis is a common postpartum complication that can occur after vaginal or cesarean delivery. The client may also have foul-smelling vaginal discharge, chills, and fatigue.
B. Cystitis
This is wrong because cystitis is an infection of the bladder that causes pain or burning during urination, not cramping.
C. Dehydration
This is wrong because dehydration does not cause fever or persistent cramping.
D. Hypovolemic shock
This is wrong because hypovolemic shock is a condition of low blood volume that causes low blood pressure, rapid pulse, and pale skin, not fever or cramping
Full Explanation
Endometritis. This is because the client's symptoms suggest that she has endometritis, which is an infection of the lining of the uterus. Endometritis is a common postpartum complication that can occur after vaginal or cesarean delivery. The client may also have foul-smelling vaginal discharge, chills, and fatigue.
Choice B is wrong because cystitis is an infection of the bladder that causes pain or burning during urination, not cramping.
Choice C is wrong because dehydration does not cause fever or persistent cramping.
Choice D is wrong because hypovolemic shock is a condition of low blood volume that causes low blood pressure, rapid pulse, and pale skin, not fever or cramping.
A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?
A. Monitor the newborn's blood glucose level hourly.
This is wrong because monitoring the newborn’s blood glucose level hourly is not necessary for phototherapy.
B. Apply lotion to the newborn's skin twice per day.
This is wrong because applying lotion to the newborn’s skin twice per day can interfere with the effectiveness of phototherapy and increase the risk of skin irritation.
C. Encourage the newborn to breastfeed every 2 hr.
Encourage the newborn to breastfeed every 2 hr.This is because breastfeeding helps the newborn to excrete bilirubin through stool and urine. Breastfeeding also prevents dehydration, which can worsen jaundice. The nurse should also monitor the newborn’s weight, hydration status, and bilirubin levels during phototherapy.
D. Maintain the newborn in a prone position.
This is wrong because maintaining the newborn in a prone position can increase the risk of sudden infant death syndrome (SIDS) and limit the exposure of skin to light.
Full Explanation
Encourage the newborn to breastfeed every 2 hr. This is because breastfeeding helps the newborn to excrete bilirubin through stool and urine. Breastfeeding also prevents dehydration, which can worsen jaundice. The nurse should also monitor the newborn’s weight, hydration status, and bilirubin levels during phototherapy.
Choice A is wrong because monitoring the newborn’s blood glucose level hourly is not necessary for phototherapy.
Choice B is wrong because applying lotion to the newborn’s skin twice per day can interfere with the effectiveness of phototherapy and increase the risk of skin irritation.
Choice D is wrong because maintaining the newborn in a prone position can increase the risk of sudden infant death syndrome (SIDS) and limit the exposure of skin to light.