Nokea
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding indicates a priority outcome for this client has been met?
- A. Pain rated as 2/10 after medication
- B. Distal pulse on affected extremity 2+/4
- C. Client remains on bedrest as directed
- D. Verifies understanding of procedure
Correct Answer: B
Rationale: Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4 indicates good perfusion, meeting a priority outcome. The other options are important but secondary to circulation.
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A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would assess the locally primary interview?
- A. Assessing blood pressure in both upper extremities
- B. Auscultating the carotid arteries for any bruits
- C. Classifying capillary refill of 4 seconds as normal
- D. Palpating both carotid arteries at the same time
Correct Answer: D
Rationale: The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.
A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)
- A. Apply compression stockings
- B. Assist with ambulation
- C. Assist with deep breathing
- D. Offer fluids frequently
- E. Teach leg exercises
Correct Answer: A,B,D
Rationale: The UAP can apply compression stockings, assist with ambulation, and offer fluids to prevent DVT. Deep breathing does not reduce DVT risk, and teaching is a nursing function.
A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?
- A. Assess the client's neurological status
- B. Notify the Rapid Response Team
- C. Prepare to administer vitamin K
- D. Turn down the infusion rate
Correct Answer: B
Rationale: Clients on fibrinolytic therapy are at high risk of bleeding. Sudden neurologic signs may indicate a hemorrhagic stroke. The nurse should first call the Rapid Response Team based on the client's manifestations, then perform a thorough neurological examination.
What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)
- A. Administering mild analgesics for pain
- B. Applying elastic compression stockings
- C. Elevating the legs when sitting or lying
- D. Reminding the client to do leg exercises
- E. Teaching the client about surgical options
Correct Answer: B,C,D
Rationale: The plan of care for varicose veins includes elastic compression stockings, exercise, and elevation. Administering analgesics is pharmacologic, and teaching about surgical options is not a comfort measure.
A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse?
- A. Administer oxygen via non-rebreather mask
- B. Ensure the client has a patent airway
- C. Prepare to assist with suturing the artery
- D. Start two large-bore IVs with normal saline
Correct Answer: B
Rationale: Airway always takes priority, followed by breathing and circulation. Ensuring a patent airway is the first step before other interventions.