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A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?
- A. Temperature of 37.9° C (100.2° F)
- B. Pallor in the affected extremity
- C. Bruising around the incisional site
- D. Urine output 150 mL over 4 hr
Correct Answer: B
Rationale: The correct answer is B: Pallor in the affected extremity. Pallor in the affected extremity post arterial revascularization could indicate compromised blood flow, potentially leading to ischemia or thrombosis. This is a critical finding that requires immediate intervention to prevent further complications such as tissue necrosis or limb loss.
Incorrect choices:
A: Temperature elevation may indicate infection, but it is not an immediate concern postoperatively.
C: Bruising around the incisional site is common after surgery and may not require immediate intervention unless there are signs of excessive bleeding.
D: Urine output of 150 mL over 4 hr is within normal limits and not a priority concern in this context.
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A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
- A. Instruct the client to use their elbows to reposition.
- B. Remove the weights before changing the client's bedlinens.
- C. Check pressure points every 12 hr.
- D. Provide the client with a trapeze bar.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a trapeze bar. This is essential for the client in skeletal traction to independently move and reposition themselves safely without putting additional stress on the affected leg. Using elbows (A) can disrupt the traction. Removing weights (B) can lead to complications. Checking pressure points (C) is important but not specific to this situation. The trapeze bar (D) promotes client independence and safety.
A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?
- A. Projectile vomiting
- B. Decorticate posturing
- C. Restlessness
- D. Papilledema
Correct Answer: C
Rationale: The correct answer is C: Restlessness. In early stages of increased ICP, the brain tries to compensate by increasing blood flow to maintain perfusion, leading to restlessness. Projectile vomiting (A) is a late sign due to pressure on the vomiting center. Decorticate posturing (B) and papilledema (D) are late signs of increased ICP.
A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
- A. I will limit my portions of meat to 8 ounces.
- B. I will increase my intake of canned vegetables.
- C. I will use canola oil when making salad dressing.
- D. I will drink whole milk with my cereal.
Correct Answer: C
Rationale: The correct answer is C: "I will use canola oil when making salad dressing." Canola oil is a healthier choice than other oils, as it is low in saturated fats and high in monounsaturated fats, which are beneficial for cardiovascular health. Using canola oil in salad dressing can help decrease the intake of unhealthy fats. Choice A is incorrect because limiting meat portions alone may not address overall dietary fat intake. Choice B is incorrect as canned vegetables may contain added sodium, which is not ideal for cardiovascular health. Choice D is incorrect as whole milk is high in saturated fats, not recommended for cardiovascular disease.
A nurse is providing discharge teaching to a client who has COPD. Which of the following instructions should the nurse include in the teaching?
- A. Consume a diet that is high in calories.
- B. Limit fluid intake to prevent mucus production.
- C. Engage in strenuous exercise daily.
- D. Reduce carbohydrate intake to prevent fatigue.
Correct Answer: A
Rationale: The correct answer is A: Consume a diet that is high in calories. Patients with COPD often have increased energy needs due to the increased work of breathing. Providing a high-calorie diet helps maintain energy levels and prevent weight loss. Choice B is incorrect because adequate hydration is crucial to help thin mucus and make it easier to clear from the airways. Choice C is incorrect as strenuous exercise can exacerbate COPD symptoms; moderate exercise is recommended. Choice D is incorrect because carbohydrates are an essential energy source and reducing intake can lead to increased fatigue in COPD patients.
A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hr. Which of the following actions should the nurse take in managing the client's PICC line?
- A. Access the catheter using a non-coring needle.
- B. Change the transparent membrane dressing daily.
- C. Maintain a continuous IV infusion through the PICC line.
- D. Flush the catheter with a 0.9% sodium chloride solution after each use.
Correct Answer: D
Rationale: Correct Answer: D - Flush the catheter with a 0.9% sodium chloride solution after each use.
Rationale: Flushing the catheter with 0.9% sodium chloride solution after each use helps prevent clot formation, maintains patency, and ensures proper functioning of the PICC line. This action also helps prevent infection and occlusions.
Incorrect Choices:
A: Accessing the catheter using a non-coring needle is not necessary for routine care of a PICC line.
B: Changing the transparent membrane dressing daily may increase the risk of infection and disrupt the integrity of the dressing.
C: Maintaining a continuous IV infusion through the PICC line is not indicated for a client receiving intermittent IV bolus antibiotics.
E, F, G: No additional choices provided.