Nokea
A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?
- A. Administer prescribed pain medication
- B. Assess distal pulses and skin color
- C. Document the findings in the client's chart
- D. Notify the surgeon immediately
Correct Answer: B
Rationale: Assessing distal pulses and skin color is the priority to ensure adequate circulation post-surgery. Severe pain could indicate complications like graft occlusion. Administering pain medication, documenting, or notifying the surgeon are secondary until circulation is confirmed.
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A client with peripheral artery disease (PAD) makes the following statements to the nurse. Which indicates the need for further teaching?
- A. I should avoid using heating pads on my legs
- B. I need to walk until I feel pain, then rest
- C. I should keep my legs elevated when resting
- D. It's going to be really hard but I will stop smoking
Correct Answer: A
Rationale: Clients with PAD should avoid heating pads due to decreased skin sensitivity, which can lead to burns. This statement shows understanding, so no further teaching is needed for it. The other statements align with proper PAD management.
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.
The nurse is assessing a client on admission to the hospital. The client's leg appears with dependent rubor. What action by the nurse is best?
- A. Assess the client's ankle-brachial index
- B. Elevate the leg above the heart
- C. Obtain an ice pack to provide comfort
- D. Administer heparin sodium
Correct Answer: A
Rationale: Dependent rubor is a classic finding in peripheral arterial disease. The nurse should measure the ankle-brachial index to assess the severity. Elevating the leg or using ice could worsen circulation, and heparin is not indicated for this condition.
Which factors does the nurse teach as contributing to aneurysm formation? (Select all that apply.)
- A. Atherosclerosis
- B. Down syndrome
- C. Frequent heartburn
- D. History of hypertension
- E. History of smoking
Correct Answer: A,D,E
Rationale: Atherosclerosis, hypertension, and smoking are major risk factors for aneurysm formation. Down syndrome and heartburn are not related.
A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Administering preoperative medication
- B. Ensuring the consent is signed
- C. Marking pulses with a pen
- D. Raising the side rails of the bed
- E. Recording the client's vital signs
Correct Answer: D,E
Rationale: The UAP can raise the side rails for safety and record vital signs. Administering medications, ensuring consent, and marking pulses should be done by the registered nurse.