Nokea
A client has undergone an amputation of several toes and a femoral-popliteal bypass. The nurse should teach the client that after surgery which of the following leg positions is contraindicated for her while sitting in a chair?
- A. Crossing the legs
- B. Elevating the legs
- C. Flexing the ankles
- D. Extending the knees
Correct Answer: A
Rationale: Crossing the legs is contraindicated post-femoral-popliteal bypass and toe amputation, as it compresses blood vessels, impairing circulation and increasing the risk of graft occlusion or ischemia. Elevating legs, flexing ankles, and extending knees are generally acceptable unless otherwise specified.
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The nurse is caring for a client who is receiving prescribed aspirin. Which of the following findings would indicate the client is having an adverse effect?
- A. Polyuria
- B. Hypokalemia
- C. Venous thromboembolism
- D. Black, tarry stools
Correct Answer: D
Rationale: Black, tarry stools indicate gastrointestinal bleeding, a serious adverse effect of aspirin due to its antiplatelet and irritant properties.
A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown below. At 10:30 a.m., the client complains of sharp midchest pain after having a bowel movement. What should the nurse do first?
- A. Assess the client's vital signs
- B. Administer a bolus of lactated Ringer's solution
- C. Assess the client's neurologic status
- D. Contact the physician
Correct Answer: A
Rationale: Sharp midchest pain in a client with a thoracic aneurysm suggests possible dissection or rupture, a life-threatening emergency. Assessing vital signs (e.g., hypotension, tachycardia) first provides critical data to guide action. Fluid bolus, neurologic assessment, or contacting the physician follow based on findings.
A postmenopausal client is scheduled for a bone-density scan. To plan for the client's test, what should the nurse communicate to the client?
- A. Request that the client remove all metal objects on the day of the scan.
- B. Instruct the client to consume foods and beverages with a high content of calcium for 2 days before the test.
- C. Inform the client that she will need to ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test.
- D. Tell the client that she should report any significant pain to her physician at least 2 days before the test.
Correct Answer: A
Rationale: Metal objects can interfere with the bone-density scan, so they must be removed. Calcium intake or pain reporting is not required for the test.
A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply.
- A. Monitor serum creatinine and blood urea nitrogen levels.
- B. Administer a sedative.
- C. A. Administer humidified oxygen.
- D. Auscultate the lungs.
Correct Answer: C,D
Rationale: Administering humidified oxygen (C) improves oxygenation in ARDS. Auscultating lungs (D) monitors crackles and ventilation. Creatinine/BUN monitoring is unrelated to acute respiratory status. Sedatives may depress respiration.
Three hours ago a client was thrown from a car into a ditch, and he is now admitted to the emergency department in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. For which signs and symptoms should the nurse be especially alert?
- A. Infection
- B. Deformity
- C. Shock
- D. None of the above
Correct Answer: C
Rationale: An open fracture increases the risk of infection and deformity, but shock is a critical systemic complication that can develop rapidly due to blood loss or pain, requiring vigilant monitoring.