Nokea
The 80-year-old client is being discharged home after having surgery to débride a chronic venous ulcer on the right ankle. Which referral would be most appropriate for the client?
- A. Occupational therapist.
- B. Social worker.
- C. Physical therapist.
- D. Cardiac rehabilitation.
Correct Answer: B
Rationale: A social worker (B) coordinates home care for an elderly client with a chronic ulcer. OT (A) and PT (C) are less relevant, and cardiac rehab (D) is unrelated.
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The nurse is caring for a client diagnosed with deep vein thrombosis. Which information reported to the nurse by the unlicensed assistive personnel (UAP) requires immediate intervention?
- A. The UAP informed the nurse the client is complaining of chest pain.
- B. The UAP notified the nurse the client’s blood pressure is 100/66.
- C. The UAP reported the client is requesting to be able to take a shower.
- D. The UAP tells the nurse the client is asking for medication for a headache.
Correct Answer: A
Rationale: Chest pain in DVT (A) suggests pulmonary embolism, requiring immediate intervention. Hypotension (B), showering (C), and headache (D) are less urgent.
The client admitted with a diagnosis of pneumonia complains of tenderness and pain in the left calf, and the nurse assesses a positive Homans’ sign. Which interventions should the nurse implement? List in order of priority.
- A. Notify the health-care provider.
- B. Initiate an intravenous line.
- C. Monitor the client’s PTT.
- D. Administer a continuous heparin infusion.
- E. Instruct the client not to get out of the bed.
Correct Answer: A,E,B,D,C
Rationale: 1. Notify HCP (A): Calf pain and positive Homans’ suggest DVT, requiring urgent evaluation. 2. Instruct bedrest (E): Prevents clot dislodgement. 3. Initiate IV (B): Prepares for heparin. 4. Administer heparin (D): Treats DVT post-order. 5. Monitor PTT (C): Ensures therapeutic heparin levels.
The HCP prescribes an HMG-CoA reductase inhibitor (statin) medication to a client with CAD. Which should the nurse teach the client about this medication?
- A. Take this medication on an empty stomach.
- B. This medication should be taken in the evening.
- C. Do not be concerned if muscle pain occurs.
- D. Check your cholesterol level daily.
Correct Answer: B
Rationale: Statins are most effective in the evening (B) due to cholesterol synthesis peaking at night. Food (A) enhances absorption, muscle pain (C) requires reporting, and daily checks (D) are unnecessary.
The nurse is admitting a client diagnosed with peripheral vascular disease. Which data support a diagnosis of venous insufficiency?
- A. The client has bright red skin on the lower extremities.
- B. The client has a brownish purple area on the lower legs.
- C. The client complains of pain after ambulating for short distances.
- D. The client has nonhealing wounds on the toes and ankles.
Correct Answer: B
Rationale: Brownish purple skin (B) indicates hemosiderin from venous stasis. Red skin (A) is nonspecific, pain with walking (C) is arterial, and toe/ankle wounds (D) are arterial.
The nurse is monitoring a client post-percutaneous coronary intervention (PCI). Which finding requires immediate action?
- A. Heart rate of 80 beats per minute
- B. Bleeding at the catheter site
- C. Blood pressure of 130/85 mmHg
- D. Mild discomfort at the insertion site
Correct Answer: B
Rationale: Bleeding at the catheter site can indicate a hematoma or hemorrhage, requiring immediate intervention.