Nokea
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
- A. Irregular ulcer shapes and severe edema.
- B. Hairless lower extremities and cool feet.
- C. Black ulcers and dependent rubor.
- D. Absent pedal pulses and shiny skin.
Correct Answer: A
Rationale: Irregular ulcer shapes and severe edema are characteristic of venous ulcers, caused by impaired venous return and increased capillary pressure.
You may also like to solve these questions
Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?
- A. Perform a complete mental status exam.
- B. Determine if the client has had a shingles vaccination.
- C. Teach the client about phantom pain symptoms.
- D. Complete an assessment of the client's pain.
Correct Answer: D
Rationale: Completing a pain assessment is the most important action to identify the cause, severity, and impact of the pain, likely postherpetic neuralgia, to plan appropriate interventions.
A client with acute renal injury (AKI) weighs 110.3 pounds (50 kg) and has a potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to the hospital. Which prescribed medication should the nurse administer first?
- A. Sodium polystyrene sulfonate 15 grams by mouth.
- B. Sevelamer one tablet by mouth.
- C. Calcium acetate one tablet by mouth.
- D. Epoetin alfa, recombinant 2,500 units subcutaneously.
Correct Answer: A
Rationale: Sodium polystyrene sulfonate is a medication that binds to excess potassium in the gastrointestinal tract and removes it from the body through feces. It is used to treat hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can cause cardiac arrhythmias and muscle weakness, and it is a common complication of AKI. Therefore, this medication should be administered first to lower the potassium level and prevent life-threatening complications.
The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which finding(s) should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply.)
- A. Abdominal obesity.
- B. Blood pressure of 150/96 mm Hg.
- C. Elevated high density lipoproteins.
- D. Increased triglyceride levels.
- E. Hyperglycemia.
- F. Hypothyroidism.
Correct Answer: A,B,D,E
Rationale: Abdominal obesity, elevated blood pressure, increased triglyceride levels, and hyperglycemia are components of metabolic syndrome that increase the risk of diabetes and vascular disease, requiring intervention.
The nurse is caring for a client who had a cholecystectomy two days ago. The client is febrile, reporting upper abdominal pain radiating to the back and has had three episodes of vomiting in the last 8 hours. The nurse reviews the client's serum amylase and lipase level results which are twice the normal value. Based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition?
- A. Hepatorenal failure.
- B. Acute pancreatitis.
- C. Surgical site infection.
- D. Biliary duct obstruction.
Correct Answer: B
Rationale: Acute pancreatitis is indicated by fever, upper abdominal pain radiating to the back, vomiting, and elevated amylase and lipase levels, likely triggered by the cholecystectomy.
A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?
- A. Sleep with the head of the bed flat.
- B. Take sedatives prior to sleep.
- C. Begin a weight loss program.
- D. Drink 1 to 2 glasses of wine at bedtime.
Correct Answer: C
Rationale: Beginning a weight loss program can reduce OSA by decreasing fat deposits around the neck and chest, which compress the airway, improving breathing during sleep.