Nokea
A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?
- A. Cool skin
- B. Numbness
- C. Edema
- D. Pallor
Correct Answer: C
Rationale: Edema is a common finding with thrombophlebitis due to venous inflammation and obstruction of blood flow, which leads to fluid accumulation in the affected limb.
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A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longer certain he wants to have the procedure. Which of the following responses should the nurse make?
- A. Why have you changed your mind about the surgery?
- B. Your provider would not have scheduled the surgery unless you needed it.
- C. I will call your doctor and have him discuss your surgery with you.
- D. Bypass surgery must be very frightening for you.
Correct Answer: D
Rationale: Bypass surgery must be very frightening for you. This response uses a therapeutic communication technique by acknowledging the client's emotions and opening the conversation for further exploration of their concerns.
A nurse is caring for a client who is newly-admitted and has angina. The client asks the nurse, 'Why am I taking nitroglycerin?' Which of the following responses should the nurse make?
- A. Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart.
- B. Nitroglycerin relieves nausea and prevents vomiting, which could lead to aspiration.
- C. Nitroglycerin acts as a bronchodilator to open small airways and decrease shortness of breath.
- D. Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries.
Correct Answer: A
Rationale: Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart. Nitroglycerin works by dilating the coronary arteries, increasing blood flow and oxygen delivery to the heart muscle, thereby reducing angina.
A nurse is reinforcing teaching about the prevention of deep vein thrombosis (DVT) with a group of newly licensed nurses. Which of the following interventions should the nurse include in the teaching?
- A. Limit movement of the lower extremities.
- B. Place sequential compression devices bilaterally.
- C. Massage lower extremities daily.
- D. Check for negative Homans' sign.
Correct Answer: B
Rationale: Place sequential compression devices bilaterally. Sequential compression devices (SCDs) help promote venous return and prevent venous stasis, thereby reducing the risk of DVT.
A nurse is reviewing the laboratory findings of a client who experienced an acute myocardial infarction 6 days ago. Which of the following laboratory values should the nurse expect to remain elevated at this time?
- A. Troponin T
- B. Creatinine phosphokinase
- C. Myoglobin
- D. Creatinine kinase-MB
Correct Answer: A
Rationale: Troponin T remains elevated for 10 to 14 days after a myocardial infarction. This protein is highly specific for cardiac muscle injury and is used to confirm myocardial infarction.
A nurse is reviewing the prescriptions for a newly admitted client who is to undergo cardiac testing. For which of the following procedures should the nurse verify that the client has given written informed consent?
- A. Exercise ECG stress test
- B. Electrocardiogram
- C. CT scan without contrast dye
- D. Echocardiogram
Correct Answer: A
Rationale: Exercise ECG stress test requires informed consent because it involves physical activity that may place stress on the heart and carries certain risks, such as inducing arrhythmias or other complications.