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One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse encourages the client to:
- A. Apply heat to the extremity
- B. Elevate the legs above the heart
- C. Stop smoking
- D. Begin a jogging program
Correct Answer: C
Rationale: Stopping smoking promotes vasodilation by reducing nicotine-induced vasoconstriction and improving endothelial function, critical in arterial occlusive disease. Applying heat risks burns in ischemic tissue, elevating legs worsens arterial flow, and jogging may be contraindicated due to claudication.
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A 21-year-old male client is transported by ambulance to the emergency department after a serious automobile accident. He complains of severe pain in his right chest where he struck the steering wheel. Which is the primary client goal at this time?
- A. Reduce the client's anxiety.
- B. Maintain adequate oxygenation.
- C. Decrease chest pain.
- D. Maintain adequate circulating volume.
Correct Answer: B
Rationale: Maintaining adequate oxygenation is the primary goal in chest trauma to prevent hypoxia from pneumothorax or hemothorax. Anxiety, pain, and volume are secondary priorities.
The nurse is providing discharge instructions for a client with cirrhosis. Which of the following statements best indicates that the client has understood the teaching?
- A. I should eat a high-protein, high-carbohydrate diet to provide energy.'
- B. It is safer for me to take acetaminophen (Tylenol) for pain instead of aspirin.'
- C. I should avoid constipation to decrease chances of bleeding.'
- D. If I get enough rest and follow my diet, it is possible for my cirrhosis to be cured.'
Correct Answer: C
Rationale: Avoiding constipation (C) prevents ammonia buildup and bleeding risks. High-protein diets (A) may worsen encephalopathy, acetaminophen (B) is hepatotoxic, and cirrhosis is irreversible (D).
The client with chronic pancreatitis should be monitored closely for the development of which of the following disorders?
- A. Cholelithiasis.
- B. Hepatitis.
- C. Irritable bowel syndrome.
- D. Diabetes mellitus.
Correct Answer: D
Rationale: Chronic pancreatitis damages pancreatic tissue, impairing insulin production and increasing the risk of diabetes mellitus (D). Cholelithiasis (A), hepatitis (B), and irritable bowel syndrome (C) are less directly related.
Which factor besides the degree of neutropenia does the nurse assess in determining the client's risk of infection?
- A. Length of time neutropenia has existed.
- B. Health status before neutropenia.
- C. Body build and weight.
- D. Resistance to infection in childhood.
Correct Answer: A
Rationale: The duration of neutropenia significantly affects infection risk, as prolonged neutropenia increases exposure to pathogens. Pre-existing health status, body build, and childhood resistance are less directly relevant to current infection risk.
A client is receiving an I.V. infusion of 5% dextrose in water (D5W). The skin around the I.V. insertion site is red, warm to touch, and painful. The nurse should first:
- A. Administer acetaminophen (Tylenol)
- B. Change the D5W to normal saline
- C. Discontinue the I.V.
- D. Place a warm compress on the area
Correct Answer: C
Rationale: Redness, warmth, and pain at the I.V. site indicate phlebitis or infiltration. The first action is to discontinue the I.V. to prevent further tissue damage. Changing fluids, applying a compress, or giving acetaminophen does not address the immediate issue.