the nurse is assessing an immobile patient for deep vein thromboses dvts which action will the nurse take
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HESI LPN

HESI Fundamentals Study Guide

1. The healthcare provider is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the healthcare provider take?

Correct answer: B

Rationale: The correct action when assessing an immobile patient for deep vein thromboses (DVTs) is to measure the calf circumference of both legs. This helps in detecting swelling or changes that may indicate the presence of a DVT. Removing elastic stockings every 4 hours (Choice A) is not necessary and can disrupt circulation. Lightly rubbing the lower leg for redness and tenderness (Choice C) can potentially dislodge a clot if present. Dorsiflexing the foot while assessing for patient discomfort (Choice D) is not a specific assessment for DVT and may not provide relevant information in this context.

2. The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?

Correct answer: B

Rationale: The correct answer is B. Rheumatic fever often follows a strep throat infection, which is why the nurse should suspect this association. Strep throat is caused by Group A Streptococcus bacteria, which can trigger an abnormal immune response leading to rheumatic fever. Choices A, C, and D are incorrect because chickenpox, ear infections, and fungal skin infections are not typically associated with rheumatic fever.

3. A mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse?

Correct answer: A

Rationale: The correct answer is A: 'Folic acid should be taken before and after conception.' Folic acid supplementation before and during early pregnancy has been shown to significantly reduce the risk of neural tube defects. Choice B is incorrect because while multivitamin supplements are beneficial during pregnancy, the specific focus for preventing neural tube defects is on folic acid. Choice C is a general statement about a well-balanced diet and does not specifically address neural tube defects. Choice D is incorrect as it focuses on dietary iron, which is important for overall health but not specifically proven to prevent neural tube defects.

4. A nurse on a med-surg unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma?

Correct answer: C

Rationale: The correct answer is C. It is an ethical dilemma when the family of a client with a terminal illness asks healthcare providers not to inform the client of their diagnosis. This situation poses a conflict between respecting the client's right to know the truth about their condition (autonomy and truth-telling principles) and honoring the family's wishes. Choices A, B, and D do not present ethical dilemmas. Choice A involves professional accountability and responsibility, Choice B involves a client's personal preference, and Choice D involves financial challenges.

5. The nurse is caring for a 17-month-old child with acetaminophen poisoning. Which laboratory reports should the nurse review first?

Correct answer: D

Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the drug's metabolism in the liver. Monitoring liver enzymes such as AST and ALT is crucial as they indicate liver function and damage. Prothrombin time (PT) and partial thromboplastin time (PTT) (Choice A) are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts (Choice B) are not directly related to acetaminophen poisoning. Blood urea nitrogen and creatinine levels (Choice C) assess kidney function, but liver enzymes are more specific for evaluating liver damage in acetaminophen poisoning.

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