Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?
a. Hematocrit 55%
b. Presence of plethora
c. Calf swelling and pain
d. Platelet count 450,000/?L
ANS: C
The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.
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A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation?
a. Stridor b. Friction rub c. Crackles d. Wheezing
If a woman is at risk for thrombus and is not ready to ambulate, nurses might intervene by doing all of these interventions except:
a. Putting her in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots. b. Having her flex, extend, and rotate her feet, ankles, and legs. c. Having her sit in a chair. d. Notifying the physician immediately if a positive Homans' sign occurs.
The home health nurse instructs the family whose child came home from school with lice that the bed linens should be:
a. thrown out in a sealed garbage bag. b. washed with strong bleach solution. c. washed and dried on the hottest setting. d. washed and dried at least through three cycles.
Predisposing conditions that promote the development of hypothermia include which of the following? (Select all that apply.)
A. Cold water immersion B. Obesity C. Low birth weight D. Shock E. Cold weather F. Extremes of ageG. Alcohol intoxicationH. Malnutrition I. Prior history of trauma