Nokea
The client asks the nurse what can be done to alleviate the pain and discomfort associated with varicose veins. Which response by the nurse is best?
- A. “Dangle your legs off the side of the bed as often as possible to alleviate the pain.”
- B. “There isn’t much you can do about the pain except have surgery to remove the veins.”
- C. “You should wear long pants to hide bulging veins; this will help your self-confidence.”
- D. “Wear elastic stockings to promote venous return; these will also help reduce discomfort.”
Correct Answer: D
Rationale: The best response to alleviate pain and discomfort associated with varicose veins includes application of elastic stockings and elevating the lower extremities. These promote venous return. Dangling legs, surgery as the only option, or wearing long pants do not address the pain effectively.
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At 0745 hours, the nurse is informed by the HCP that a cardiac catheterization is to be completed on the client at 1400 hours. Which intervention should be the nurse’s priority?
- A. Place the client on NPO (nothing per mouth) status.
- B. Teach the client about the cardiac catheterization.
- C. Start an intravenous (IV) infusion of 0.9% NaCl.
- D. Witness the client’s signature on the consent form.
Correct Answer: A
Rationale: A cardiac catheterization is an invasive procedure requiring the client to lie still in a supine position. The client is usually sedated with medication, such as midazolam, during the procedure. To avoid aspiration, the client should be NPO 6 to 12 hours prior to the procedure, making this the priority at 0745 for a 1400 procedure.
The nurse is assessing the client with an 8-centimeter AAA. Which finding should the nurse expect?
- A. Report of persistent nagging pain in the upper anterior chest
- B. Systolic bruit palpated over the upper abdomen
- C. Edema of the face and neck with distended neck veins
- D. A pulsating mass in the mid to upper abdomen
Correct Answer: D
Rationale: Throbbing or pulsating in the abdomen is the sign most indicative of an AAA. Chest pain, edema, and neck vein distention are associated with thoracic aneurysms, and a bruit is auscultated, not palpated.
The client newly diagnosed with HF has an ejection fraction of 20%. Which criteria should the nurse use to evaluate the client’s readiness for discharge to home? Select all that apply.
- A. There is a scale in the client’s home
- B. The client started ambulating 24 hours ago
- C. The client is receiving furosemide IV 20 mg bid
- D. A smoking cessation consult is scheduled for 2 days after discharge
- E. A home-care nurse is scheduled to see the client 3 days after discharge
Correct Answer: A;B;E
Rationale: The nurse should evaluate: A) A scale to monitor fluid status; B) Ambulation to confirm functional capability; E) Home-care nurse visit within 3 days for support. IV furosemide (C) should be oral before discharge, and smoking cessation (D) should start before discharge.
The nurse fails to obtain scheduled VS at 0200 hours for the client who had cardiac surgery 2 days ago. After assessing the client at 0600 hours, the nurse documents the 0600 HR for both the 0200 and 0600 VS. Which conclusion should a supervising charge nurse make about the nurse’s actions? Select all that apply.
- A. The nurse’s action was acceptable; neither complications nor harmful effects occurred.
- B. The nurse’s action is concerning legally; the nurse fraudulently falsified documentation.
- C. The nurse’s action demonstrates beneficence; the nurse decided what was best for the client.
- D. The nurse’s action is extremely concerning; it involves the ethical issue of veracity.
- E. The nurse’s action demonstrates distributive justice; other clients’ needs were priority.
Correct Answer: B;D
Rationale: The charge nurse should conclude: B) Falsifying documentation is a legal concern; D) The action involves the ethical issue of veracity (truthfulness). The action is not acceptable (A), does not show beneficence (C), and there’s no evidence of distributive justice (E).
Upon assessing the client who has distal foot pain due to vascular insufficiency, the nurse notes the wound illustrated. When reviewing the client’s medical record, which notation is the nurse likely to find?
- A. Venous ulcer on left foot
- B. Arterial ulcer on right foot
- C. Diabetic ulcer on left foot
- D. Stress ulcer on right foot
Correct Answer: B
Rationale: The nurse should find a notation of an arterial ulcer on the right foot. Arterial ulcers typically occur on the feet; they are deep, and the ulcer bed is pale with even, defined edges and limited granulation tissue. Venous ulcers are at the ankle, diabetic ulcers are plantar, and stress ulcers are gastric.