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1. What are the risk factors for deep vein thrombosis (DVT) and how can it be prevented?
- A. Immobility and oral contraceptive use
- B. Pregnancy and smoking
- C. Obesity and varicose veins
- D. Hypertension and high cholesterol
Correct answer: A
Rationale: The correct answer is A: Immobility and oral contraceptive use. Immobility and oral contraceptive use are significant risk factors for deep vein thrombosis (DVT). Immobility leads to blood stasis, increasing the risk of clot formation, while oral contraceptive use can promote hypercoagulability. Prevention strategies for DVT include promoting mobility to enhance blood circulation and using anticoagulants to prevent clot formation. Choices B, C, and D are incorrect. While pregnancy and smoking can increase the risk of DVT, they are not the specific factors mentioned in the question. Similarly, obesity and varicose veins, as well as hypertension and high cholesterol, are not the primary risk factors associated with DVT.
2. A nurse is caring for a client with a pressure ulcer. Which of the following interventions is most appropriate?
- A. Administer a protein supplement
- B. Increase protein intake in the client's diet
- C. Increase IV fluid intake to improve hydration
- D. Cleanse the wound from the center outwards
Correct answer: D
Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps prevent infection and promotes healing by ensuring that any contaminants are moved away from the center of the wound. Administering a protein supplement (choice A) or increasing protein intake in the client's diet (choice B) may be beneficial for overall healing but are not the most appropriate interventions specifically for wound care. Increasing IV fluid intake (choice C) is important for hydration but is not the most appropriate intervention for managing a pressure ulcer.
3. A client is learning about preventing hip dislocation before total hip arthroplasty. Which instruction should be included?
- A. Avoid bending the hip more than 90 degrees
- B. Avoid lying on the unaffected side
- C. Avoid crossing the legs at the knees
- D. Avoid keeping the legs in a neutral position
Correct answer: C
Rationale: The correct instruction to prevent hip dislocation after total hip arthroplasty is to avoid crossing the legs at the knees. This position can put stress on the hip joint and increase the risk of dislocation. Choices A, B, and D are incorrect. Bending the hip more than 90 degrees, lying on the unaffected side, or keeping the legs in a neutral position are not directly related to preventing hip dislocation in this context.
4. What is the main symptom of left-sided heart failure?
- A. Shortness of breath
- B. Edema
- C. Increased heart rate
- D. Decreased urine output
Correct answer: A
Rationale: Shortness of breath is the main symptom of left-sided heart failure because it results from pulmonary congestion due to fluid buildup in the lungs. Edema, increased heart rate, and decreased urine output are associated with right-sided heart failure rather than left-sided heart failure.
5. A client with type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?
- A. Your weight gain should be less than that for someone without diabetes.
- B. Your weight gain should be the same as that for someone without diabetes.
- C. You should not avoid gaining weight during pregnancy.
- D. You should gain more weight to support the pregnancy.
Correct answer: B
Rationale: During pregnancy, a client with type 2 diabetes mellitus should aim for a weight gain similar to someone without diabetes to ensure a healthy pregnancy. Choice A is incorrect because weight gain should not be less; it should be adequate for pregnancy. Choice C is inaccurate as gaining some weight is essential for a healthy pregnancy. Choice D is incorrect as gaining more weight than necessary can pose risks for both the client and the baby.
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