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A client with a venous leg ulcer is receiving compression therapy. What assessment finding requires immediate intervention?
- A. Decreased pain and increased redness around the ulcer.
- B. Increased serous drainage from the ulcer site.
- C. Cool extremities and weak peripheral pulses.
- D. Pitting edema around the ulcer site.
Correct Answer: C
Rationale: The correct answer is C. Cool extremities and weak peripheral pulses indicate compromised circulation, possibly due to inadequate arterial blood supply. This finding requires immediate intervention to prevent further complications such as tissue damage or non-healing ulcers. Option A, decreased pain and increased redness, can be a sign of improving wound condition. Option B, increased serous drainage, may indicate a normal part of the healing process. Option D, pitting edema, is common in venous leg ulcers and may not require immediate intervention unless severe and accompanied by other concerning symptoms.
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A client with a history of stroke is receiving warfarin. What is the nurse's priority assessment?
- A. Check the client's blood pressure.
- B. Assess for signs of bleeding.
- C. Assess the client's neurological status.
- D. Monitor the client's intake and output.
Correct Answer: B
Rationale: The correct answer is to assess for signs of bleeding. Warfarin is an anticoagulant that increases the risk of bleeding in patients. Monitoring for signs of bleeding such as easy bruising, petechiae, blood in urine or stool, or unusual bleeding from gums is crucial. Checking the client's blood pressure (choice A) is important but not the priority in this situation. Assessing the client's neurological status (choice C) is essential in stroke patients but is not the priority related to warfarin therapy. Monitoring intake and output (choice D) is important for overall assessment but is not the priority when a client is on warfarin, as assessing for bleeding takes precedence.
A client is experiencing angina at rest. Which statement indicates a good understanding of the care required?
- A. I will notify the nurse if my chest pain is not relieved in 30 minutes.
- B. I will use nitroglycerin as needed, every 5 minutes, up to 3 doses.
- C. I will avoid physical activity until the pain subsides completely.
- D. I will take nitroglycerin 30 minutes before any physical activity.
Correct Answer: B
Rationale: The correct answer is B. Using nitroglycerin as needed, every 5 minutes, up to 3 doses, is the appropriate management for angina at rest. This helps dilate blood vessels, improving blood flow to the heart. Choice A is incorrect because chest pain that persists at rest should be addressed immediately, not waiting for 30 minutes. Choice C is incorrect as avoiding physical activity is not a recommended approach during an angina episode. Choice D is incorrect because nitroglycerin should be used during chest pain episodes, not as a preventive measure before physical activity.
A nurse is working with a new graduate nurse on the delegation of tasks to the unlicensed assistive personnel (UAP). Which task would the new nurse need more teaching about delegating?
- A. Taking a client's blood pressure
- B. Providing oral hygiene for a client
- C. Assessing a client's pain level
- D. Assisting a client with ambulation
Correct Answer: C
Rationale: The correct answer is C: Assessing a client's pain level. This task involves clinical judgment and interpretation, which are within the scope of a licensed nurse's practice. Delegating pain assessment to unlicensed personnel could lead to errors in pain management and inappropriate interventions. Choices A, B, and D involve tasks that can be safely delegated to unlicensed assistive personnel as they do not involve interpretation or nursing judgment. Taking a client's blood pressure, providing oral hygiene, and assisting with ambulation are all routine tasks that can be appropriately assigned to UAP under the supervision of a licensed nurse.
A client presents to the clinic with concerns about her left breast. Which assessment finding is most important for the nurse to report?
- A. Multiple firm, round, freely movable masses.
- B. A slight asymmetry of the breasts.
- C. A fixed nodular mass with dimpling of the skin.
- D. Bloody discharge from the nipple.
Correct Answer: C
Rationale: The correct answer is C. A fixed nodular mass with dimpling of the skin is concerning for malignancy, such as breast cancer, and should be reported immediately for further evaluation. This finding is more suspicious compared to multiple firm, round, freely movable masses (choice A), which could be benign breast lumps. A slight asymmetry of the breasts (choice B) is a common finding and not as alarming as a fixed nodular mass with dimpling of the skin. Bloody discharge from the nipple (choice D) can be suggestive of other conditions like intraductal papilloma but is not as urgent as the finding described in choice C.
The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?
- A. Decreased urinary output
- B. Jugular vein distention
- C. Pleural effusion
- D. Bibasilar crackles
Correct Answer: B
Rationale: Correct! In right-sided congestive heart failure, jugular vein distention is a common finding due to the backup of blood in the systemic circulation. This results in increased venous pressure, leading to jugular vein distention. Choices A, C, and D are incorrect because decreased urinary output, pleural effusion, and bibasilar crackles are more commonly associated with other conditions such as kidney dysfunction, lung issues, and pulmonary edema.