Fundamental Concepts and Skills for Nursing Test Bank

Correct Answer: D

Rationale: The nurse should emphasize the use of ice after a sprained ankle because it helps decrease the diameter of blood vessels. By applying ice to the injured area, vasoconstriction occurs, which means the blood vessels constrict and become narrower. This helps reduce swelling, inflammation, and pain associated with the injury. Cold therapy through the application of ice is a common approach used in the immediate management of sprains and strains to promote healing and alleviate discomfort.

Correct Answer: C

Rationale: Pulmonary embolism (PE) is a serious condition where a blood clot travels to the lungs and blocks blood flow, which can be life-threatening. Common clinical manifestations of PE include sudden onset of dyspnea (difficulty breathing), chest pain (sharp, stabbing pain that may worsen with deep breaths), tachypnea (rapid breathing), tachycardia (rapid heart rate), and possibly cough or hemoptysis (coughing up blood). In the context of a client recovering from a hysterectomy, it is crucial to recognize the signs of PE as early intervention is essential to prevent serious complications. Nausea, decreased urine output, and activity intolerance are not typical clinical manifestations of a pulmonary embolism and should not be the primary focus when suspecting a PE in this scenario.

Correct Answer: A

Rationale: A. Muscle spasms: Nitroprusside infusion can lead to cyanide toxicity, which can cause muscle spasms as a symptom. It is essential for the nurse to monitor the client for any signs of muscle spasms during the infusion.

Correct Answer: D

Rationale: The correct instruction for a client who is scheduled for temporary pacemaker insertion is to use battery-powered equipment. This is because temporary pacemakers are powered by an external power source, typically a battery pack worn by the client. Therefore, it is important for the client to be aware of this and ensure that they have access to the necessary battery-powered equipment at home for the pacemaker to function properly. The other options are not appropriate instructions for a client with a temporary pacemaker.

Correct Answer: A

Rationale: Low blood flow in veins increases the risk for the development of a thrombus. When blood flow is slow or stagnant in veins, it can lead to the formation of blood clots or thrombi. This risk is further heightened in individuals who have conditions that affect blood flow, such as being sedentary or having a condition that impairs circulation. Thrombi can pose serious health risks if they break off and travel to other parts of the body, potentially causing blockages or even life-threatening complications like pulmonary embolism. Thus, low blood flow in veins is a key characteristic that increases the risk for thrombus formation.