NU 160 Exam 1

Correct Answers: 

Oral contraceptive use

Immobility

Explanation:

Deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein, most commonly in the legs. Risk factors include conditions that slow blood flow, increase clotting, or damage the veins.

Oral contraceptive use 

Birth control pills containing estrogen and progestin can increase the risk of blood clot formation by increasing blood coagulability. Women who smoke or have additional risk factors (such as obesity or a history of DVT) are at even greater risk.

Immobility 

Prolonged immobility (e.g., bed rest, long flights, or paralysis) reduces blood circulation, leading to venous stasis. This stagnation increases the likelihood of clot formation in the deep veins.

Why the Other Options Are Incorrect:

BMI of 20 

A BMI of 20 is within the normal range (18.5-24.9). Obesity (BMI ≥30) is a known risk factor for DVT because excess weight puts pressure on veins and can slow circulation, but a BMI of 20 does not increase risk.

Hypertension 

While high blood pressure affects cardiovascular health, it is not a direct risk factor for DVT. DVT is more closely related to blood stasis and hypercoagulability rather than hypertension alone.

High calcium intake 

Calcium intake does not increase DVT risk. While excessive calcium can affect vascular health in other ways (e.g., artery calcification), it does not directly contribute to clot formation in veins.

Summary:

The correct answers are oral contraceptive use and immobility, as both contribute to blood stasis and increased clotting risk. The other options (BMI of 20, hypertension, and high calcium intake) do not directly cause or increase the risk of deep vein thrombosis.

Correct Answer:  Pain, pallor, and paresthesia in the foot

Explanation:

The presence of pain, pallor, and paresthesia in the foot suggests acute arterial ischemia, which requires immediate intervention. These symptoms indicate a critical reduction in blood flow, potentially due to arterial occlusion (acute limb ischemia). If left untreated, this condition can rapidly progress to tissue necrosis and limb loss. Emergency interventions such as anticoagulation, thrombolysis, or surgical intervention (embolectomy or bypass surgery) may be required.

Why the Other Options Are Incorrect

Lower extremities edematous with decreased pulses and cool to the touch

While this finding suggests chronic peripheral artery disease (PAD), it does not indicate an immediate threat to the limb. PAD often leads to poor circulation, weak pulses, and cool skin, but it progresses gradually over time. Immediate intervention is not necessary unless symptoms suddenly worsen, such as in the case of acute arterial occlusion.

Presence of an open wound near the ankle with serous drainage and pruritus

This finding is more indicative of peripheral venous disease (PVD) rather than PAD. Venous ulcers typically develop near the medial malleolus (inner ankle) and are associated with chronic venous insufficiency, edema, and itching. While venous ulcers require treatment, they are not as immediately life-threatening as acute arterial occlusion.

Murmur auscultated at the left 5th midclavicular line, slight dyspnea, and lower extremity edema

A murmur heard at the 5th intercostal space, midclavicular line suggests mitral valve disease (e.g., mitral regurgitation or stenosis). Although this condition requires cardiac evaluation, it is not directly related to PAD and does not demand immediate intervention unless severe heart failure or hemodynamic instability is present.

Summary

The most urgent finding is pain, pallor, and paresthesia in the foot, as it indicates acute arterial ischemia, which can quickly lead to permanent tissue damage and limb loss. The other findings suggest chronic vascular conditions that require medical management but do not pose an immediate threat to the patient’s life or limb.

Correct Answer: Encourage the client to walk.

Explanation:

For a client with deep-vein thrombosis (DVT) receiving anticoagulation therapy, encouraging ambulation is essential as it promotes circulation and prevents further clot formation. Walking helps reduce venous stasis and supports the body's natural ability to break down the clot over time.

Why the Other Options Are Incorrect:

Apply cold compresses to the affected extremity –

Cold compresses are not recommended for DVT because they cause vasoconstriction, which may worsen circulation and increase clot formation. Warm compresses are sometimes used to alleviate discomfort but are not the primary intervention.

Massage the affected extremity gently 

Massaging the affected limb is contraindicated because it can dislodge the clot, increasing the risk of a pulmonary embolism, which is a life-threatening complication.

Apply compression stockings at bedtime 

Compression stockings should be applied in the morning before getting out of bed when the legs are least swollen, not at bedtime. This helps prevent blood pooling and reduces swelling.

Summary:

For a client with DVT on anticoagulation therapy, encouraging ambulation is the best intervention as it promotes circulation and prevents complications. Applying cold compresses, massaging the extremity, or using compression stockings at bedtime are either ineffective or potentially harmful.

The correct answers are

A: Protein

 B: Phosphorous

D: Sodium.

Explanation:

Chronic kidney disease (CKD) requires careful dietary management to reduce the kidneys' workload and prevent further damage. The following nutrients are commonly restricted for individuals with CKD:

A: Protein

In CKD, the kidneys have difficulty filtering waste products from protein metabolism. High protein intake can exacerbate kidney damage by increasing the kidneys' workload. Therefore, clients with CKD are often instructed to limit their protein intake to prevent further strain on the kidneys.

B: Phosphorous

Phosphorous is a mineral found in many foods, and when kidney function declines, the kidneys are less able to excrete phosphorous. Elevated phosphorous levels can lead to bone problems and cardiovascular issues. Clients with CKD are often advised to limit phosphorous-containing foods, such as dairy products, nuts, and certain meats.

D: Sodium

Sodium is restricted in CKD because it contributes to fluid retention, which can lead to high blood pressure and swelling. Excess sodium intake can also worsen kidney function. By limiting sodium, clients with CKD can help manage fluid balance and blood pressure, both of which are critical in slowing the progression of the disease.

Why The Other Options Are Incorrect

C: Calcium

Calcium is typically not restricted in CKD unless there are specific complications, such as hypercalcemia, where calcium levels are already too high in the blood. In fact, calcium is important for bone health, and patients with CKD may need calcium supplements, especially if they are on phosphate binders that reduce calcium absorption. However, excessive calcium can cause problems, so it is important to monitor levels, but generally, calcium intake is not a primary concern compared to phosphorous or sodium.

E: Calories

Calories are typically not restricted unless the patient is overweight or has other conditions, such as diabetes. For the most part, clients with CKD need to maintain their weight and nutritional status, so calorie intake is not a major restriction unless it is a specific concern for the patient’s overall health or comorbid conditions.

Summary:

Clients with CKD should primarily limit protein, phosphorous, and sodium to reduce kidney workload, prevent fluid retention, and avoid complications such as bone disease. Calcium is not typically restricted unless there are specific issues with calcium metabolism, and calories are generally not restricted unless there is an issue with weight management or other conditions like diabetes.

Correct Answer: "Exercise at least three times per week."

Explanation:

Regular moderate exercise is beneficial for clients with heart failure (HF) as it helps improve cardiovascular function, endurance, and overall well-being. Exercise can also help reduce fluid retention, improve circulation, and strengthen the heart muscle. However, it is essential that clients follow an individualized exercise plan prescribed by their healthcare provider, typically including low-impact activities such as walking or cycling while avoiding overexertion.

Why the Other Options Are Incorrect:

"Notify the provider of a weight gain of 0.5 kg (1 lb) in a week."

Incorrect: A weight gain of 1 lb (0.5 kg) in a week is not necessarily alarming. Clients should notify their provider if they experience a sudden weight gain of 2–3 lbs (0.9–1.4 kg) in a day or 5 lbs (2.3 kg) in a week, as this may indicate fluid retention and worsening heart failure.

"Take naproxen for generalized discomfort."

Incorrect: NSAIDs like naproxen should be avoided in heart failure because they can cause fluid retention, increase blood pressure, and worsen kidney function, all of which can exacerbate heart failure symptoms. Instead, acetaminophen (Tylenol) is a safer alternative for pain relief in HF patients.

"Take diuretics early in the morning and before bedtime."

Incorrect: While taking diuretics early in the morning is correct to prevent nocturnal diuresis (frequent urination at night), taking them before bedtime is not recommended as it may disrupt sleep due to frequent urination. If a second dose is needed, it should be taken in the early afternoon rather than at night.

Summary:

The correct instruction is to exercise at least three times per week, as it improves heart function, circulation, and overall health in HF patients. The other options are incorrect because they either provide inaccurate guidance on weight monitoring, recommend a medication (naproxen) that can worsen HF, or suggest an inappropriate diuretic schedule.

The correct answer is B. Administer subcutaneous Humalog.

Explanation 

Licensed Practical Nurses (LPNs) are permitted to administer subcutaneous insulin, including Humalog (insulin lispro), as it falls within their scope of practice. LPNs commonly provide routine medication administration, including subcutaneous injections, under the supervision of a registered nurse (RN) or healthcare provider.

Explanation of Incorrect Answers:

A. Hang a new bag of Total Parenteral Nutrition (TPN)

TPN is a highly specialized intravenous (IV) nutritional therapy that requires careful monitoring, sterile technique, and knowledge of fluid and electrolyte balance. It is considered high-risk because incorrect administration can lead to metabolic complications or infections. Only an RN or provider should initiate, adjust, or hang a new bag of TPN.

C. Start a blood transfusion 

Blood transfusions require initial assessment, verification of patient identity, and monitoring for transfusion reactions, which are responsibilities that must be performed by an RN. While LPNs may assist in monitoring a stable patient after the transfusion has begun, they cannot start the transfusion.

D. Administer IV morphine 

LPNs cannot administer IV push medications, including IV narcotics like morphine. IV medications require careful dosing, assessment of response, and monitoring for adverse reactions such as respiratory depression, which is within the RN’s scope of practice. Some state boards of nursing may allow LPNs to administer IV medications with additional certification, but this is not standard practice.

Summary:

The best task to delegate to an LPN is administering subcutaneous Humalog because it is within their scope of practice. The other options involve high-risk IV therapies (TPN, blood transfusions, and IV morphine) that require an RN’s expertise to ensure safe administration and monitoring. Proper delegation improves workflow efficiency while ensuring patient safety.

Correct Answer: "I may eat 10 ounces of lean protein each day."

Explanation:

For clients with hypertension, a heart-healthy diet typically emphasizes moderation and balance in all food groups. The statement about consuming 10 ounces of lean protein each day indicates a need for further teaching because 10 ounces is an excessive amount of protein, which could lead to increased intake of calories and fats, even if the protein is lean. Typically, a healthy serving of protein for an adult would be about 3-6 ounces per meal, depending on individual dietary needs.

Why the Other Statements Are Correct:

"Fresh fruits make a good snack option."

This is correct. Fresh fruits are naturally low in sodium, high in fiber, and rich in vitamins and minerals, making them a great choice for a heart-healthy diet.

"I will replace table salt with dried herbs."

This is also correct. Reducing sodium intake is essential for managing hypertension. Replacing table salt with dried herbs and spices is a good strategy to enhance flavor without adding sodium.

"I may thicken gravies with cornstarch as I cook."

This is correct. Cornstarch is a low-sodium thickening agent and can be used to thicken gravies without adding unnecessary sodium, making it a better option than using pre-made gravies or high-sodium thickeners.

Summary:

The statement about consuming 10 ounces of lean protein daily indicates a need for further teaching. A heart-healthy diet for clients with hypertension emphasizes portion control, particularly for protein, and focuses on fresh fruits, reducing sodium intake, and using low-sodium alternatives for flavoring and thickening foods.

The correct answer is: A. Hyperkalemia

Explanation:

The oliguric phase of acute kidney injury (AKI) is characterized by a significant reduction in urine output (less than 400 mL per day). During this phase, the kidneys are not able to excrete waste products and electrolytes efficiently. As a result, hyperkalemia (elevated potassium levels) is a common finding. Potassium, which is normally excreted by the kidneys, builds up in the bloodstream due to impaired renal function. This can lead to dangerous cardiac arrhythmias, so monitoring and managing potassium levels are critical during this phase of AKI.

Why The Other Options Are Incorrect

B. Increased glomerular filtration rate (GFR)

During the oliguric phase of AKI, the GFR is decreased, not increased. This is due to kidney damage and impaired filtration capacity. As a result, waste products such as creatinine and urea accumulate in the blood, and urine output significantly decreases.

C. Hypomagnesemia

In the oliguric phase of AKI, hypermagnesemia (elevated magnesium levels) is more likely to occur rather than hypomagnesemia. Like potassium, magnesium is typically excreted by the kidneys. When kidney function declines, magnesium can accumulate in the bloodstream, leading to elevated levels, which can cause neuromuscular and cardiovascular problems.

D. Decreased creatinine level

Creatinine is a waste product of muscle metabolism that is typically excreted by the kidneys. In the oliguric phase of AKI, creatinine levels increase due to impaired kidney function and the kidneys' inability to eliminate waste effectively. A decreased creatinine level would not be expected in this phase.

Summary:

In the oliguric phase of acute kidney injury, hyperkalemia (elevated potassium levels) is the most likely finding, as the kidneys are unable to excrete potassium efficiently. The other findings, such as an increased GFR, hypomagnesemia, and decreased creatinine levels, are not typical of this phase of AKI.

Correct Answer: Take the medication early in the day.

Rationale:

Hydrochlorothiazide is a thiazide diuretic prescribed to help manage hypertension by increasing urine output and reducing fluid retention. Since this medication causes increased urination, taking it early in the day helps prevent nocturia, which is frequent urination at night that can disrupt sleep.

Explanation of Incorrect Options:

Weigh weekly to monitor therapeutic effect

This option is incorrect because clients at risk for fluid imbalances, such as those with heart failure, are usually advised to weigh themselves daily rather than weekly. In the case of hypertension, the effectiveness of hydrochlorothiazide is better monitored by regularly checking blood pressure rather than weight changes.

Take the medication on an empty stomach

This option is incorrect because hydrochlorothiazide can be taken with or without food. Some clients may experience stomach irritation, so taking it with food can help minimize gastrointestinal discomfort.

Muscle pain is an expected adverse effect

This option is incorrect because muscle pain or cramps may indicate hypokalemia, which is a serious side effect of hydrochlorothiazide. Hypokalemia occurs when the medication causes excessive potassium loss through urination, leading to symptoms such as muscle weakness, cramping, or irregular heartbeat. The nurse should instruct the client to report any muscle pain, cramps, or weakness immediately rather than considering it a normal or expected reaction.

Key Teaching Points for Hydrochlorothiazide:

The medication should be taken in the morning to prevent sleep disturbances from frequent urination at night. Blood pressure should be monitored regularly to assess the effectiveness of the medication. The client should be aware of potential signs of hypokalemia, which include muscle weakness, cramps, and irregular heartbeat, and report them to a healthcare provider. Potassium-rich foods, such as bananas, oranges, spinach, and potatoes, may be beneficial if advised by the healthcare provider to help maintain potassium levels. The client should stay adequately hydrated but avoid excessive salt intake, which can counteract the effects of the medication.

Summary:

The most appropriate instruction is to take the medication early in the day to prevent nighttime urination while ensuring effective management of hypertension.