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A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Administering preoperative medication
- B. Ensuring the consent is signed
- C. Marking pulses with a pen
- D. Raising the side rails of the bed
- E. Recording the client's vital signs
Correct Answer: D,E
Rationale: The UAP can raise the side rails for safety and record vital signs. Administering medications, ensuring consent, and marking pulses should be done by the registered nurse.
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The nurse is assessing a client on admission to the hospital. The client's leg appears with dependent rubor. What action by the nurse is best?
- A. Assess the client's ankle-brachial index
- B. Elevate the leg above the heart
- C. Obtain an ice pack to provide comfort
- D. Administer heparin sodium
Correct Answer: A
Rationale: Dependent rubor is a classic finding in peripheral arterial disease. The nurse should measure the ankle-brachial index to assess the severity. Elevating the leg or using ice could worsen circulation, and heparin is not indicated for this condition.
What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)
- A. Administering mild analgesics for pain
- B. Applying elastic compression stockings
- C. Elevating the legs when sitting or lying
- D. Reminding the client to do leg exercises
- E. Teaching the client about surgical options
Correct Answer: B,C,D
Rationale: The plan of care for varicose veins includes elastic compression stockings, exercise, and elevation. Administering analgesics is pharmacologic, and teaching about surgical options is not a comfort measure.
A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Ambulate the client
- B. Apply a warm moist pack
- C. Massage the client's leg
- D. Provide an ice pack
Correct Answer: B
Rationale: Warm moist packs can help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.
A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)
- A. Apply compression stockings
- B. Assist with ambulation
- C. Assist with deep breathing
- D. Offer fluids frequently
- E. Teach leg exercises
Correct Answer: A,B,D
Rationale: The UAP can apply compression stockings, assist with ambulation, and offer fluids to prevent DVT. Deep breathing does not reduce DVT risk, and teaching is a nursing function.
The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning?
- A. Cholesterol: 126 mg/dL
- B. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL
- C. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL
- D. Triglycerides: 198 mg/dL
Correct Answer: D
Rationale: Triglycerides in men should be below 160 mg/dL. The other values are within acceptable ranges for adult males.