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A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for complications?
- A. Palpate the client's brachial pulses and compare bilaterally.
- B. Check for jugular vein distention while the client is supine.
- C. Check the client's blood pressure while the client lies supine, sits, and stands.
- D. Palpate the client's pedal pulses and compare bilaterally.
- E. Monitor respiratory rate.
- F. Check for chest pain.
- G. Assess skin temperature.
Correct Answer: D
Rationale: Pedal pulses assess for femoral artery complications like hematoma or occlusion.
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A nurse is preparing to administer warfarin to a client who has chronic atrial fibrillation. Which of the following laboratory values should the nurse monitor prior to administering the medication?
- A. LDL
- B. INR
- C. BUN
- D. Hct
Correct Answer: B
Rationale: INR (International Normalized Ratio) measures clotting time and must be monitored with warfarin to ensure therapeutic anticoagulation and prevent bleeding or clotting complications in atrial fibrillation.
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Replace the unit when the drainage chamber is full.
- B. Monitor for at least 150 mL of drainage every hour.
- C. Clamp the tube for 30 min every 8 hr.
- D. Pin the tubing to the client's bed sheets.
Correct Answer: A
Rationale: Chest tube systems remove pleural air or fluid, requiring functionality. Replacing the unit when full prevents backpressure or overflow, maintaining drainage and lung re-expansion, per manufacturer and infection control standards (e.g., CDC). Monitoring 150 mL/hr is excessive sudden high output signals hemorrhage, not routine care. Clamping risks tension pneumothorax by trapping air/fluid, only done briefly for specific checks (e.g., air leak). Pinning tubing prevents dislodgement, but full chamber replacement is the proactive maintenance action. This ensures system efficacy, prevents complications like atelectasis, and aligns with respiratory care priorities, making it the nurse's key responsibility.
A nurse is assisting in the care of the client who has iron deficiency anemia. Which of the following statements indicate the client understands the instructions?
- A. I should increase green leafy vegetables in my diet.
- B. The iron supplement might cause my stools to be black.
- C. I should expect to have swelling in my feet.
- D. I will take my iron supplement 1 hour before a meal.
Correct Answer: B
Rationale: Iron supplements oxidize in the gut, often turning stools black due to unabsorbed iron a normal, expected effect clients should recognize to avoid alarm. Green leafy vegetables (e.g., spinach) boost dietary iron, but oxalates limit absorption, making this less indicative of supplement-specific teaching. Swelling in feet isn't a typical iron effect edema suggests heart or kidney issues, not anemia treatment. Taking iron 1 hour before meals aids absorption, a good practice, but the question emphasizes understanding therapy outcomes. Black stools confirm the client grasps a common, visible side effect, aligning with education goals (e.g., managing expectations), ensuring adherence and reducing unnecessary worry, making it the clearest sign of comprehension.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform breast exams the day my period begins.
- B. I will perform breast exams every other month.
- C. It is common for the skin on my breasts to dimple.
- D. It is common for one breast to be larger than the other.
Correct Answer: D
Rationale: It's normal for one breast to be slightly larger than the other, and this statement reflects an accurate understanding of breast anatomy. Dimpling can be a sign of concern, and exams should be done monthly, about a week after the period starts, not on the first day or every other month.
A nurse is caring for a client who has dysphagia following a stroke. The nurse should recommend a referral to which of the following members of the interdisciplinary team?
- A. Speech therapist
- B. Respiratory therapist
- C. Occupational therapist
- D. Physical therapist
Correct Answer: A
Rationale: A speech therapist addresses dysphagia by assessing swallowing and recommending strategies, critical after a stroke. Other therapists focus on different rehabilitation aspects.