Nokea
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?
- A. I wake up to go to the bathroom at night
- B. My shoes fit tighter by the end of the day
- C. I drink at least eight glasses of water a day
- D. I have gained 5 pounds in the last month
Correct Answer: B
Rationale: Edema is characterized by fluid accumulation in interstitial spaces, often causing swelling that makes shoes or clothing feel tighter, especially at the end of the day. This symptom is indicative of edema, unlike the other options.
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A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)
- A. Thrombophlebitis
- B. Stroke
- C. Pulmonary embolism
- D. Myocardial infarction
- E. Cardiac tamponade
Correct Answer: A,C,E
Rationale: Right-sided heart catheterization carries risks of thrombophlebitis, relationships pulmonary embolism, and cardiac tamponade. Stroke and myocardial infarction are more commonly associated with left-sided catheterizations.
A nurse monitors a client 2 hours after a cardiac catheterization. Which findings would require immediate action? (Select all that apply.)
- A. Blood pressure of 142/88 mm Hg
- B. Serum potassium of 2.9 mEq/L
- C. Warmth and redness at the site
- D. Expanding hematoma
- E. Rhythm changes on the cardiac monitor
Correct Answer: B,D,E
Rationale: Hypokalemia (2.9 mEq/L), an expanding hematoma, and rhythm changes are serious complications requiring immediate action. Slightly elevated blood pressure and warmth/redness (if not severe) are less urgent in the immediate post-procedure period.
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse suspect?
- A. Heart rate of 120 beats/min
- B. Cool, clammy skin
- C. Oxygen saturation of 90%
- D. Respiratory rate of 8 breaths/min
Correct Answer: A
Rationale: When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node, resulting in an increased heart rate. A heart rate of 120 beats/min is indicative of tachycardia, which is a compensatory mechanism for low blood pressure.
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
- A. Excruciating pain on inspiration
- B. Left lateral chest wall pain
- C. Disorientation or confusion
- D. Numbness and tingling of the arm
Correct Answer: C
Rationale: In older adults, myocardial infarction may present with atypical symptoms such as disorientation or confusion due to poor cardiac output and reduced cerebral perfusion. While pain or numbness may occur, confusion is a critical manifestation in this population.
A nurse reviews a client's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.)
- A. Total cholesterol: 280 mg/dL
- B. High-density lipoprotein cholesterol: 50 mg/dL
- C. Triglycerides: 200 mg/dL
- D. Serum albumin: 4 g/dL
- E. High-density lipoprotein cholesterol: 30 mg/dL
Correct Answer: A,C,E
Rationale: Elevated total cholesterol (280 mg/dL), elevated triglycerides (200 mg/dL), and low high-density lipoprotein cholesterol (30 mg/dL) are associated with increased risk of atherosclerosis. Serum albumin is not related to atherosclerosis risk, and an HDL of 50 mg/dL is within normal limits.