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An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice nurse. What statement by the client may indicate a barrier to proper foot care?
- A. I nearly always wear comfy sweatpants and house shoes
- B. I'm glad I get energy assistance so my house isn't so cold
- C. I check my feet every day for cuts or sores
- D. My hands shake when I try to do things requiring coordination
Correct Answer: D
Rationale: Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails, indicating a barrier to proper foot care. The nurse should refer this client to a podiatrist.
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A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.)
- A. Dietary restrictions
- B. Driving restrictions
- C. Follow-up laboratory monitoring
- D. Drug-drug interactions
- E. Reason to take medication
Correct Answer: A,C,D,E
Rationale: Clients on warfarin need instructions on dietary restrictions, follow-up monitoring, drug interactions, and the reason for the medication, per The Joint Commission's Core Measures. Driving restrictions are not typically required.
A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the diagnosis. What action by the nurse is best?
- A. Assess the client's support system
- B. Assist in finding one change the client can control
- C. Determine what stressors the client faces in daily life
- D. Inquire about delegating some of the client's obligations
Correct Answer: B
Rationale: All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Assisting the client in choosing one change they feel optimistic about controlling is the most effective approach to build confidence and promote adherence.
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.
A nurse wants to provide community service that helps meet the goals of Healthy People 2020 related to cardiovascular disease and stroke. What activity would best meet this goal?
- A. Teach a class on heart-healthy diets
- B. Participate in blood pressure screenings at the mall
- C. Provide pamphlets on heart disease at the grocery store
- D. Set up an information booth at the pet store
Correct Answer: B
Rationale: An important goal of Healthy People 2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether it was normal or high. Blood pressure screenings in a public place best meet this goal.
The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?
- A. A 4-ounce steak, French fries, iceberg lettuce
- B. Baked chicken breast, broccoli, tomatoes
- C. Fried catfish, cornbread, peas
- D. Spaghetti with meat sauce, garlic bread
Correct Answer: B
Rationale: The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is baked chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.