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A client with peripheral arterial disease (PAD) has cool and pale feet with diminished pulses. Which of the following interventions should the nurse implement?
- A. Keep the legs elevated above the level of the heart.
- B. Encourage the client to exercise daily.
- C. Apply warm compresses to the affected area.
- D. Apply ice packs to the affected area.
Correct Answer: C
Rationale: In peripheral arterial disease (PAD), there is decreased blood flow to the extremities. Applying warm compresses helps dilate blood vessels, improve circulation, and relieve symptoms. Elevating the legs above the heart level may further compromise blood flow. Encouraging daily exercise is important in PAD management but may not be appropriate when the client has cool, pale feet with diminished pulses. Applying ice packs can worsen vasoconstriction and further reduce blood flow, exacerbating symptoms in PAD.
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The nurse is monitoring a client with chronic renal failure who is receiving hemodialysis. The nurse should report which of the following findings immediately?
- A. Clear dialysate outflow.
- B. Weight gain of 2 lbs (0.9 kg) since the last treatment.
- C. Blood pressure of 130/80 mm Hg.
- D. Pulse rate of 72 bpm.
Correct Answer: B
Rationale: The correct answer is B. Weight gain of 2 lbs (0.9 kg) since the last treatment is concerning in a client undergoing hemodialysis with chronic renal failure as it may indicate fluid overload. This finding requires immediate reporting and intervention to prevent complications such as fluid retention, pulmonary edema, or exacerbation of heart failure. Choices A, C, and D are not findings that require immediate attention in this context. Clear dialysate outflow is a normal finding during hemodialysis, a blood pressure of 130/80 mm Hg is within a normal range for many clients, and a pulse rate of 72 bpm is also within the expected range for most individuals.
A client diagnosed with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurses to instruct the client about self-care?
- A. Call the clinic if undesirable side effects of medications occur
- B. Avoid crowded enclosed areas to reduce pathogen exposure
- C. Increase the daily intake of oral fluids to liquefy secretions
- D. Teach anxiety reduction methods for feelings of suffocation
Correct Answer: C
Rationale: Increasing the daily intake of oral fluids is crucial for clients with asthma and bronchitis as it helps to liquefy thickened mucus, making it easier to clear the airways and manage symptoms. This self-care measure can improve the client's ability to breathe more effectively. Choice A is not the most immediate concern when addressing thickened mucus and breathing difficulties. While avoiding crowded areas is beneficial to prevent respiratory infections, it is not directly related to managing thickened secretions. Teaching anxiety reduction methods is important for overall well-being, but it does not directly address the physiological issue of thickened mucus in the airways.
The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?
- A. Protect the skin of the radiation portal site from sunlight exposure
- B. Apply moisturizing lotions daily to the radiation portal site
- C. Avoid washing the skin inside the radiation portal site
- D. Remove the ink marks of the portal after each radiation treatment
Correct Answer: A
Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.
Which instruction should be included in the discharge teaching plan for a client who underwent cataract extraction today?
- A. Use a metal eye shield on the operative eye during the day.
- B. Administer eye ointment before applying eye drops.
- C. Sexual activities may be resumed after returning home.
- D. Light housekeeping is safe to do, but avoid heavy lifting.
Correct Answer: D
Rationale: The correct instruction to include in the discharge teaching plan for a client who underwent cataract extraction is to advise them that light housekeeping is safe to do, but they should avoid heavy lifting. Heavy lifting can strain the surgical site and potentially lead to complications. Choice A is incorrect as a metal eye shield is usually recommended during sleep, not during the day. Choice B is incorrect because eye ointment should typically be administered after applying eye drops to prevent dilution of the medication. Choice C is incorrect as sexual activities should usually be avoided for a specific period post-surgery as advised by the healthcare provider.
When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of 'visual sensory/perceptual alterations.' This problem is based on which etiology?
- A. Blurred distance vision
- B. Limited eye movement
- C. Decreased peripheral vision
- D. Photosensitivity
Correct Answer: C
Rationale: The correct answer is 'C: Decreased peripheral vision.' Open-angle glaucoma leads to a gradual loss of peripheral vision due to damage to the optic nerve. This loss of peripheral vision is a hallmark sign of the condition and a primary reason for the visual sensory/perceptual alterations experienced by the client. Blurred distance vision (choice A) may occur but is not the priority nursing problem. Limited eye movement (choice B) and photosensitivity (choice D) are not typically associated with the sensory/perceptual alterations seen in open-angle glaucoma.