Nokea
The client diagnosed with arterial occlusive disease is one (1) day postoperative right femoral-popliteal bypass. Which intervention should the nurse implement?
- A. Keep the right leg in the dependent position.
- B. Apply sequential compression devices to lower extremities.
- C. Monitor the client's pedal pulses every shift.
- D. Assess the client's leg dressing every four (4) hours.
Correct Answer: C
Rationale: Monitoring pedal pulses (C) assesses graft patency post-bypass, critical to ensure circulation. Dependent position (A) impairs flow, compression devices (B) are for venous issues, and dressing checks (D) are routine but secondary.
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Which finding in a client with mitral stenosis requires immediate action?
- A. Heart rate of 100 beats per minute
- B. New onset of atrial fibrillation
- C. Blood pressure of 140/90 mmHg
- D. Mild fatigue
Correct Answer: B
Rationale: New-onset atrial fibrillation increases the risk of thromboembolism in mitral stenosis, requiring immediate intervention.
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.
The nurse is teaching a class on venous insufficiency. The nurse would identify which condition as the most serious complication of chronic venous insufficiency?
- A. Arterial thrombosis.
- B. Deep vein thrombosis.
- C. Venous ulcerations.
- D. Varicose veins.
Correct Answer: C
Rationale: Venous ulcerations (C) are the most serious complication of chronic venous insufficiency, causing infection risk and impaired healing. Arterial thrombosis (A) is unrelated, DVT (B) is a separate condition, and varicose veins (D) are less severe.
Which assessment data would cause the nurse to suspect the client has atherosclerosis?
- A. Change in bowel movements.
- B. Complaints of a headache.
- C. Intermittent claudication.
- D. Venous stasis ulcers.
Correct Answer: C
Rationale: Intermittent claudication (C) indicates arterial insufficiency from atherosclerosis. Bowel changes (A) and headaches (B) are nonspecific, and venous ulcers (D) are venous-related.
The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse?
- A. The telemetry reads normal sinus rhythm.
- B. The client has a weight gain of 2 kg within 1 to 2 days.
- C. The client's blood pressure is 148/92.
- D. The client's serum potassium level is 4.5 mEq.
Correct Answer: B
Rationale: Weight gain of 2 kg in 1–2 days (B) indicates fluid retention, a serious issue in hypertension requiring intervention. Normal sinus rhythm (A), BP 148/92 (C), and K+ 4.5 (D) are not urgent.