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A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
- A. Elevate the leg and apply a sandbag to the entrance site.
- B. Increase the flow rate of intravenous fluids.
- C. Assess the color and temperature of the left leg.
- D. Document the finding as the left pedal pulse of +1/4.
Correct Answer: C
Rationale: A weak pedal pulse after cardiac angiography may indicate compromised blood flow. Assessing the color and temperature of the leg helps determine if there is ischemia or other complications.
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Which vaccines must be delayed for 11 months after the administration of gamma globulin? (Select all that apply.)
- A. Diphtheria, tetanus, and pertussis
- B. Hepatitis B
- C. Inactivated polio virus
- D. Measles, mumps, and rubella
Correct Answer: D
Rationale: Live virus vaccines (MMR and Varicella) should be delayed for 11 months after gamma globulin infusion because the passive antibodies can interfere with vaccine efficacy.
The following are true about water excretion:
- A. It is influenced by the proximal tubule
- B. It is influenced by vasopressin
- C. It depends on erythropoietin
- D. It is influenced by the ascending limb of the loop of Henle
Correct Answer: B
Rationale: It is influenced by vasopressin: Vasopressin (ADH) regulates water reabsorption in the kidneys, primarily by acting on the collecting ducts, enhancing water retention in response to dehydration.
Epiphyseal changes are seen in:
- A. Non-accidental injury
- B. Rickets
- C. Chronic renal failure
- D. Lead poisoning
Correct Answer: B
Rationale: Rickets is characterized by epiphyseal changes due to defective mineralization of growing bones.
A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110mmol/L), hematocrit of 34%, and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client?
- A. Cheese pasta and a lettuce and tomato salad
- B. Beef steak with steamed broccoli and orange slices
- C. Broiled white fish with a baked sweet potato
- D. Grilled shrimp and season rice with asparagus salad
Correct Answer: B
Rationale: The client's lab results indicate iron deficiency anemia. Beef steak is rich in iron, and vitamin C from orange slices enhances iron absorption, making this the best choice to address the anemia.
Depending on the frequency and severity of hypercyanotic attacks in tetralogy of Fallot, all the following procedures are true EXCEPT
- A. placement of the infant in the knee-chest position
- B. administration of oxygen
- C. injection of morphine subcutaneously
- D. rapid correction with intravenous sodium bicarbonate
Correct Answer: D
Rationale: Intravenous sodium bicarbonate is not typically used for hypercyanotic attacks.