Nokea
The client asks the nurse why arterial ulcers are so painful. What is the best response by the nurse?
- A. The ulcers are deep and affect the bone.
- B. The lack of oxygen to the tissue causes pain.
- C. The ulcers are infected, causing inflammation.
- D. The pressure from swelling presses on nerves.
Correct Answer: B
Rationale: Arterial ulcers are painful due to tissue ischemia from inadequate oxygen delivery, which stimulates pain receptors.
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The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client's record?
- A. Peripheral vascular disease.
- B. Intermittent claudication.
- C. Deep vein thrombosis.
- D. Dependent rubor.
Correct Answer: B
Rationale: Muscle cramping/pain with walking (B) is intermittent claudication, a hallmark of arterial occlusive disease. PVD (A) is broader, DVT (C) causes swelling/pain at rest, and dependent rubor (D) is a skin color change.
The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply.
- A. Place sequential compression devices on both legs.
- B. Instruct the client to stay in bed and not ambulate.
- C. Encourage fluids and a diet high in roughage.
- D. Monitor IV site every four (4) hours and prn.
- E. Assess Homans’ sign every 24 hours.
Correct Answer: A,C,D
Rationale: Compression devices (A), fluids/fiber (C), and IV monitoring (D) prevent DVT progression and complications. Bedrest (B) is not absolute (early ambulation is encouraged), and Homans’ sign (E) is unreliable.
When offered the pain medication, the client says to the nurse, 'If that's Motrin, I don't want it. It makes me sick to my stomach.' What is the most appropriate nursing action at this time?
- A. Tell the client that the drug is ibuprofen.
- B. Explain that the prescribed medication must be taken.
- C. Advise the client to take the drug with plenty of water.
- D. Report the information to the charge nurse.
Correct Answer: D
Rationale: Reporting the client's adverse reaction to the charge nurse ensures proper communication and potential adjustment of the medication plan.
Which medication side effect should the nurse monitor for in a client taking an ACE inhibitor?
- A. Dry cough
- B. Weight gain
- C. Increased thirst
- D. Muscle cramps
Correct Answer: A
Rationale: ACE inhibitors commonly cause a dry cough due to increased bradykinin levels.
Which instruction should the nurse include for a client with valvular heart disease?
- A. Avoid high-sodium foods.
- B. Increase caffeine intake.
- C. Limit fluid intake.
- D. Avoid regular exercise.
Correct Answer: A
Rationale: Avoiding high-sodium foods prevents fluid retention, reducing strain on the heart.