Nokea
The healthcare provider is unable to palpate the client's left pedal pulses. Which of the following actions should the healthcare provider take next?
- A. Auscultate the pulses with a stethoscope.
- B. Call the physician.
- C. Use a Doppler ultrasound device.
- D. Inspect the lower left extremity.
Correct Answer: C
Rationale: When pedal pulses are not palpable, using a Doppler ultrasound device is the appropriate next step to locate the pulse. Auscultating the pulses with a stethoscope (Choice A) is used for assessing blood flow in arteries above the clavicle, not for pedal pulses. Calling the physician (Choice B) may be necessary at a later stage, but initially, using a Doppler ultrasound device to locate the pulse is more appropriate. Inspecting the lower left extremity (Choice D) can provide visual information but will not help in locating the pedal pulses, making it a less suitable option.
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The healthcare provider is assessing an older Caucasian male who has a history of peripheral vascular disease. The healthcare provider observes that the man's left great toe is black. The discoloration is probably a result of:
- A. Atrophy.
- B. Contraction.
- C. Gangrene.
- D. Rubor.
Correct Answer: C
Rationale: Gangrene refers to dead, blackened tissue, often a result of chronic ischemia in clients with peripheral vascular disease. Atrophy (Choice A) is the wasting away or decrease in size of tissue or organ. Contraction (Choice B) refers to the shortening or tightening of a muscle or other body part. Rubor (Choice D) is a red discoloration of the skin, often associated with inflammation or poor circulation, but not typically presenting as blackening like gangrene.
The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is:
- A. Decreased blood flow.
- B. Increased blood flow.
- C. Slow blood flow.
- D. Thrombus formation.
Correct Answer: A
Rationale: The correct answer is A: 'Decreased blood flow.' In peripheral vascular disease (PVD), there is a narrowing or blockage of blood vessels, leading to reduced blood flow to the extremities. This decreased blood flow results in inadequate oxygen supply to the muscles, causing pain, especially during physical activity when oxygen demand increases. Choice B, 'Increased blood flow,' is incorrect because PVD is characterized by impaired blood circulation rather than increased flow. Choice C, 'Slow blood flow,' is not precise as PVD involves a more significant reduction in blood flow. Choice D, 'Thrombus formation,' is related to the formation of blood clots within vessels, which can be a complication of PVD but is not its main characteristic.
A client with chronic renal failure is receiving epoetin alfa (Epogen) to treat anemia. The nurse should assess the client for which of the following side effects?
- A. Hypertension.
- B. Hypotension.
- C. Infection.
- D. Edema.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Epoetin alfa (Epogen) is a medication used to treat anemia in clients with chronic renal failure. One common side effect of this medication is hypertension. Epoetin alfa stimulates red blood cell production, which can lead to an increase in blood pressure. Therefore, the nurse should closely monitor the client for signs and symptoms of hypertension while on this medication. Choices B, C, and D are incorrect. Hypotension is not typically associated with epoetin alfa administration. Infection is not a direct side effect of epoetin alfa. Edema is also not a common side effect of this medication.
The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
- A. Perform the procedure safely and correctly.
- B. Critique the nurse's performance of the procedure.
- C. Explain all steps of the procedure correctly.
- D. Correctly answer a post-test about the procedure.
Correct Answer: A
Rationale: The best indicator of learning is the ability to perform the procedure safely and correctly, demonstrating skill acquisition. Choice A is correct because the client's ability to perform the insulin self-injection safely and correctly shows practical understanding and application of the skill. Choice B is incorrect because critiquing the nurse's performance does not necessarily demonstrate the client's ability to carry out the procedure themselves. Choice C is incorrect as merely explaining the steps verbally does not confirm the client's practical execution of the task. Choice D is also incorrect as answering a post-test does not directly assess the client's ability to physically perform the insulin self-injection.
Following the diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which of the following measures would most likely help the client prevent this problem?
- A. Climb the stairs early in the day.
- B. Rest for at least an hour before climbing the stairs.
- C. Take a nitroglycerin tablet before climbing the stairs.
- D. Lie down after climbing the stairs.
Correct Answer: C
Rationale: The correct answer is to take a nitroglycerin tablet before climbing the stairs. Nitroglycerin helps prevent angina by dilating the coronary arteries, which increases blood flow to the heart. This medication can help reduce the chest pain and discomfort experienced during physical exertion. Climing the stairs early in the day (Choice A) does not address the underlying issue of inadequate blood flow to the heart. Resting for at least an hour before climbing the stairs (Choice B) may not be as effective in preventing angina as taking nitroglycerin. Lying down after climbing the stairs (Choice D) does not offer a preventive measure for angina; it is more focused on post-activity rest rather than prevention.