Nokea
A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action?
- A. A low, grade 1 intensity mitral regurgitation murmur.
- B. SpO2 is 94% on 2 liters of oxygen via nasal cannula.
- C. The client has become more somnolent.
- D. Urine output has decreased from 60 mL/hour to 40 mL over the last hour.
Correct Answer: C
Rationale: Increased somnolence may indicate neurological complications (e.g., stroke) post-valvuloplasty, requiring immediate action. Other findings are less urgent.
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The nurse should assess the client with Ménière'sdisease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Select all that apply.
- A. Antihistamines.
- B. Antiemetics.
- C. Diuretics.
- D. Non-steroidal anti-inflammatory drugs (NSAIDs).
- E. Antipyretics.
Correct Answer: A,B,C
Rationale: Common medications for Ménière'sdisease include antihistamines (e.g., meclizine) to reduce vertigo, antiemetics to control nausea, and diuretics to reduce inner ear fluid, all aimed at symptom management.
The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen-based oral contraceptives. This client is at high risk for development of:
- A. Atherosclerosis
- B. Diabetes
- C. Vasospastic disorder (Raynaud's disease)
- D. Thrombophlebitis
Correct Answer: D
Rationale: Obesity and estrogen-based oral contraceptives increase the risk of thrombophlebitis by promoting hypercoagulability and venous stasis, especially during surgery. Atherosclerosis, diabetes, and Raynaud's are less directly related to these risk factors.
A client has an epidural catheter inserted for postoperative pain management. The client rates his pain at 4 on a 0-to-5 pain scale. What should the nurse do first?
- A. Check the patient-controlled analgesia (PCA) pump function.
- B. Adjust the epidural catheter.
- C. Assess vital signs.
- D. Notify the physician.
Correct Answer: C
Rationale: Assessing vital signs first ensures the client is stable, as a pain level of 4 may indicate complications (e.g., respiratory depression). Checking the pump, adjusting the catheter, or notifying the physician follow if needed.
The nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. Which of the following are expected normal findings? Select all that apply.
- A. Reduced edema of the left knee.
- B. Skin warm to touch.
- C. Capillary refill response.
- D. A 55-year-old response.
- E. Pain absent.
- F. Pulse on left leg weaker than right leg.
Correct Answer: A,B,C
Rationale: Reduced edema, warm skin, and normal capillary refill are expected post-surgery. Pain is typically present, and pulses should be equal.
The nurse is caring for a client who has just had an ankle-brachial index (ABI) test. The left arm blood pressure was 160/80 mm Hg and a palpable systolic blood pressure of the left lower extremity was 130/60 mm Hg. These findings suggest that the client has:
- A. Mild peripheral artery disease
- B. Moderate peripheral artery disease
- C. No apparent occlusion in the left lower extremity
- D. Severe peripheral artery disease
Correct Answer: A
Rationale: ABI = ankle systolic BP ÷ arm systolic BP = 130 ÷ 160 = 0.81. An ABI of 0.8–0.9 indicates mild peripheral artery disease, suggesting some arterial narrowing. Normal ABI is 0.9–1.3, moderate is 0.5–0.8, and severe is <0.5.