Fundamental Concepts and Skills for Nursing Test Bank

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.

Correct Answer: C

Rationale: For an older patient with heart failure prescribed digoxin (Lanoxin) 125 mcg by mouth three times a week, the nurse should administer the drug as prescribed while monitoring for manifestations of toxicity. Digoxin is a medication commonly used in heart failure, but it has a narrow therapeutic index, meaning that the difference between a therapeutic dose and a toxic dose is small. Older patients are more susceptible to digoxin toxicity due to age-related changes in pharmacokinetics and pharmacodynamics, as well as potential comorbidities. Therefore, close monitoring for signs and symptoms of digoxin toxicity, such as nausea, vomiting, visual disturbances, and cardiac arrhythmias, is essential. It is important for the nurse to be vigilant for any early signs of toxicity and communicate any concerns to the healthcare provider promptly.

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: 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: C

Rationale: The statement "If I take my medications as prescribed, I'll feel better" best illustrates compliance with the medication plan. This statement shows an understanding of the importance of following the prescribed medication regimen and the potential positive outcomes of adherence to the plan. It demonstrates the client's willingness to adhere to the instructions given by the nurse, which is essential for successful medication management and treatment outcomes.