Nokea
A client with peripheral arterial disease (PAD) has cool and pale feet with diminished pulses. Which of the following interventions should the nurse implement?
- A. Keep the legs elevated above the level of the heart.
- B. Encourage the client to exercise daily.
- C. Apply warm compresses to the affected area.
- D. Apply ice packs to the affected area.
Correct Answer: C
Rationale: In peripheral arterial disease (PAD), there is decreased blood flow to the extremities. Applying warm compresses helps dilate blood vessels, improve circulation, and relieve symptoms. Elevating the legs above the heart level may further compromise blood flow. Encouraging daily exercise is important in PAD management but may not be appropriate when the client has cool, pale feet with diminished pulses. Applying ice packs can worsen vasoconstriction and further reduce blood flow, exacerbating symptoms in PAD.
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In a patient with cirrhosis, which of the following lab results is most concerning?
- A. Elevated liver enzymes.
- B. Low albumin levels.
- C. Elevated bilirubin levels.
- D. Low platelet count.
Correct Answer: D
Rationale: In a patient with cirrhosis, a low platelet count is the most concerning lab result. Thrombocytopenia, or low platelet count, is common in cirrhosis due to impaired platelet production in the liver. It significantly increases the risk of bleeding and can lead to serious complications such as hemorrhage. Elevated liver enzymes (Choice A) are expected in cirrhosis but may not directly indicate the severity of the disease. Low albumin levels (Choice B) are common in cirrhosis and can contribute to fluid retention but do not pose an immediate risk of bleeding. Elevated bilirubin levels (Choice C) are also expected in cirrhosis and typically indicate impaired liver function but do not directly increase the risk of bleeding as much as a low platelet count.
In a patient with asthma, which of the following is a primary goal of treatment?
- A. Improving oxygenation.
- B. Reducing inflammation.
- C. Improving airflow.
- D. Reducing airway constriction.
Correct Answer: C
Rationale: The primary goal in the treatment of asthma is to improve airflow. Asthma is characterized by airway inflammation, constriction, and increased mucus production, leading to airflow limitation. Improving airflow helps ensure adequate oxygenation and reduces symptoms. While reducing inflammation and airway constriction are important aspects of asthma management, the primary goal is to optimize airflow to improve respiratory function and quality of life.
Which of the following is a common cause of chronic obstructive pulmonary disease (COPD)?
- A. Smoking
- B. Asthma
- C. Allergies
- D. Chronic bronchitis
Correct Answer: A
Rationale: Smoking is the correct answer as it is a well-established common cause of chronic obstructive pulmonary disease (COPD). Smoking leads to long-term damage to the lungs, contributing to the development of COPD. Choice B, asthma, is not a cause but a separate respiratory condition characterized by airway inflammation and hyperresponsiveness. Allergies, choice C, are not a direct cause of COPD but can exacerbate symptoms in individuals with existing COPD. Chronic bronchitis, choice D, is a type of COPD, not a cause of COPD itself, making it an incorrect choice in this context.
A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. Which action should the nurse implement?
- A. Observe the perineal area for a chancroid-like lesion
- B. Obtain a specimen of urethral drainage for culture
- C. Assess for perineal itching, erythema, and excoriation
- D. Identify all sexual partners in the last four days
Correct Answer: B
Rationale: Obtaining a urethral drainage specimen for culture is crucial in diagnosing a potential sexually transmitted infection (STI) in this client. While assessing for perineal symptoms like itching, erythema, and excoriation (Choice C) may provide additional information, obtaining a culture is more definitive. Observing for a chancroid-like lesion (Choice A) is not as pertinent as obtaining a culture for a broader diagnostic approach. Identifying all sexual partners in the last four days (Choice D) is important for contact tracing but obtaining a specimen for culture takes priority in this scenario.
A young adult client, admitted to the Emergency Department following a motor vehicle collision, is transfused with 4 units of PRBCs (packed red blood cells). The client's pretransfusion hematocrit is 17%. Which hematocrit value should the nurse expect the client to have after all the PRBCs have been transfused?
- A. 0.19
- B. 0.09
- C. 0.39
- D. 0.29
Correct Answer: D
Rationale: The expected increase in hematocrit after transfusion is approximately 3% per unit of PRBCs. Since the client received 4 units, the expected increase would be 4 x 3% = 12%. Therefore, adding this to the pretransfusion hematocrit of 17% would result in an expected post-transfusion hematocrit of 29%. Choice A (0.19) is incorrect as it doesn't consider the incremental increase per unit of PRBCs. Choices B (0.09) and C (0.39) are also incorrect as they do not align with the expected increase in hematocrit following the transfusion of 4 units of PRBCs.