Nokea
An adult client is admitted to the hospital with peripheral vascular disease of the lower extremities. He has several ischemic ulcers on each ankle and lower leg area. Other parts of his skin are shiny and taut with loss of hair. A primary nursing goal for this client should be to do which of the following?
- A. Increase activity tolerance
- B. Relieve anxiety
- C. Protect from injury
- D. Help build a positive body image
Correct Answer: C
Rationale: Protecting from injury is critical for a client with peripheral vascular disease and ischemic ulcers to prevent infection and further tissue damage. Other goals are secondary.
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Which value should the nurse report immediately to the physician?
- A. Sodium: 137 mEq/L
- B. Potassium: 2.5 mEq/L
- C. Chloride: 97 mEq/L
- D. Bicarbonate: 25 mEq/L
Correct Answer: B
Rationale: Potassium of 2.5 mEq/L (hypokalemia) is critical, especially with diuretics, risking arrhythmias.
Which finding best indicates that cardiac compressions can be discontinued?
- A. The victim's color improves.
- B. The pupils become dilated.
- C. A pulse can be palpated.
- D. The victim begins to vomit.
Correct Answer: C
Rationale: A palpable pulse indicates spontaneous circulation, allowing CPR to be discontinued.
Digoxin (Lanoxin) and furosemide (Lasix) are ordered for a client who has congestive heart failure. Which of the following would the nurse also expect to be ordered for this client?
- A. Potassium
- B. Calcium
- C. Aspirin
- D. Coumadin
Correct Answer: A
Rationale: Furosemide, a diuretic, can cause potassium loss, leading to hypokalemia, which increases the risk of digoxin toxicity. Potassium supplements are often ordered to maintain normal levels.
After the coronary arteriogram, the nurse must keep the client flat in bed with the affected leg in which position?
- A. Extended
- B. Flexed
- C. Abducted
- D. Adducted
Correct Answer: A
Rationale: Keeping the leg extended prevents bleeding or hematoma at the femoral artery puncture site by minimizing movement.
The nurse is caring for an elderly client who has congestive heart failure and is taking digoxin. The client should be monitored for which of the following signs of toxicity?
- A. Disorientation
- B. Weight gain
- C. Constipation
- D. Dyspnea
Correct Answer: A
Rationale: Disorientation is a neurological sign of digoxin toxicity. Weight gain, constipation, and dyspnea are not specific to digoxin toxicity.