Nokea
A client with peripheral artery disease reports pain while walking. What intervention should the nurse recommend?
- A. Encourage the client to increase physical activity.
- B. Instruct the client to take rest breaks during walking.
- C. Apply warm compresses to the legs to improve circulation.
- D. Massage the affected leg to relieve the pain.
Correct Answer: B
Rationale: Clients with peripheral artery disease often experience claudication (leg pain during walking) due to decreased blood flow. Encouraging rest breaks during walking helps to manage pain and improve circulation. Rest breaks allow the muscles to recover from ischemia caused by inadequate blood supply. Increasing physical activity without breaks may worsen the symptoms. Applying warm compresses can potentially lead to burns or skin damage in individuals with compromised circulation. Massaging the affected leg is contraindicated in peripheral artery disease as it can further compromise blood flow.
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A client tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The client states that it still takes hours to fall asleep at night. Which action should the nurse implement?
- A. Advise the client to reduce exercise intensity
- B. Ask the client for a description of the exercise schedule that is being followed
- C. Encourage the client to try relaxation techniques before bed
- D. Suggest avoiding water-based exercise before bed
Correct Answer: B
Rationale: Asking the client for a description of the exercise schedule being followed is the most appropriate action for the nurse to take in this scenario. Understanding the timing and intensity of the client's exercise routine can help identify if the activity is contributing to sleep disturbances. Exercise too close to bedtime can cause difficulty falling asleep. Choices A, C, and D do not directly address the need to assess the exercise schedule and may not provide the necessary information to identify the potential cause of the client's sleep issue.
The nurse is preparing to administer a blood transfusion to a client. Which action is most important for the nurse to take before starting the transfusion?
- A. Administer pre-transfusion medication
- B. Ensure the client has an adequate fluid intake
- C. Monitor the client's vital signs
- D. Verify the blood type with another nurse
Correct Answer: D
Rationale: Verifying the blood type with another nurse is critical before starting a blood transfusion to prevent a potentially life-threatening transfusion reaction. This step ensures that the client receives the correct blood product. Administering pre-transfusion medication, ensuring adequate fluid intake, and monitoring vital signs are important steps during the transfusion process, but verifying the blood type is the most crucial step to ensure patient safety.
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?
- A. Encourage the client to drink more slowly
- B. Stop feeding and assess for signs of aspiration
- C. Elevate the head of the bed further
- D. Teach coughing and deep breathing exercises
Correct Answer: B
Rationale: When an older adult with aspiration pneumonia coughs while attempting to drink, it may indicate aspiration. Aspiration can lead to serious complications. Therefore, the appropriate intervention for the nurse in this situation is to stop feeding immediately and assess the client for signs of aspiration. Encouraging the client to drink more slowly (Choice A) may not address the risk of aspiration. Elevating the head of the bed further (Choice C) is generally beneficial to prevent aspiration but is not the priority when immediate assessment is needed. Teaching coughing and deep breathing exercises (Choice D) is not appropriate when the client is actively coughing during feeding and requires immediate assessment for potential aspiration.
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?
- A. Nutritional guidelines to support blood health
- B. Signs of infection to monitor for
- C. When to give pain medication
- D. Instructions about how much fluid the child should drink daily
Correct Answer: D
Rationale: Proper hydration is crucial in managing sickle cell anemia (SCA) as it helps prevent sickling of red blood cells and reduces blood viscosity, which can lead to painful crises. Ensuring the child drinks enough fluids is essential to maintain adequate hydration levels and reduce the risk of complications. While nutritional guidelines and recognizing signs of infection are important aspects of care, maintaining proper hydration is the most immediate and critical factor in managing SCA and preventing crises.
What is the expected outcome of prescribing a proton pump inhibitor to a client with a peptic ulcer?
- A. Promote healing of the gastric mucosa.
- B. Neutralize the effects of stomach acid.
- C. Inhibit the growth of Helicobacter pylori.
- D. Reduce gastric acid secretion.
Correct Answer: D
Rationale: The correct answer is D: Reduce gastric acid secretion. Proton pump inhibitors (PPIs) work by reducing gastric acid secretion, which helps prevent further irritation of the gastric mucosa and allows ulcers to heal. While promoting healing of the gastric mucosa (Choice A) is an indirect outcome of reducing gastric acid secretion, the primary mechanism of PPIs is to lower acid levels. Choice B, neutralizing the effects of stomach acid, is typically associated with antacids, not PPIs. Inhibiting the growth of Helicobacter pylori (Choice C) is usually achieved with antibiotics, not PPIs.