Nokea
The client diagnosed with Buerger’s disease (thromboangiitis obliterans) asks the nurse, 'What is the worst thing that could happen if I don’t quit smoking? I love my cigarettes.' Which statement is the nurse’s best response?
- A. You are concerned about quitting smoking. Let’s sit down and talk about it.'
- B. Many clients end up having to have an amputation, especially a leg.'
- C. You should consider attending a smoking cessation program.'
- D. Your coronary arteries could block and cause a heart attack.'
Correct Answer: B
Rationale: Smoking worsens Buerger’s, risking severe ischemia and amputation (B). Concern (A) avoids the question, cessation programs (C) are secondary, and heart attack (D) is less specific.
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The nurse is teaching a class on arterial essential hypertension. Which modifiable risk factors would the nurse include when preparing this presentation?
- A. Include information on retinopathy and nephropathy.
- B. Discuss sedentary lifestyle and smoking cessation.
- C. Include discussions on family history and gender.
- D. Provide information on a low-fiber and high-salt diet.
Correct Answer: B
Rationale: Modifiable risk factors for hypertension include sedentary lifestyle and smoking (B), which can be changed. Retinopathy/nephropathy (A) are complications, family history/gender (C) are non-modifiable, and low-fiber/high-salt (D) promotes hypertension.
The client is four (4) hours postoperative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?
- A. Assist the client to ambulate.
- B. Assess the client's bilateral pedal pulses.
- C. Maintain a continuous IV heparin drip.
- D. Provide a clear liquid diet to the client.
Correct Answer: B
Rationale: Assessing pedal pulses (B) monitors graft patency post-AAA repair, critical at 4 hours. Ambulation (A) is premature, heparin (C) is not routine, and diet (D) awaits bowel function.
The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?
- A. Administer intravenous antibiotics.
- B. Apply warm moist packs every two (2) hours.
- C. Elevate the right foot on two (2) pillows.
- D. Teach the client about skin and foot care.
Correct Answer: A
Rationale: Cellulitis requires immediate IV antibiotics (A) to treat infection, especially in diabetes. Warm packs (B), elevation (C), and teaching (D) follow to support healing and prevention.
When the nurse is planning the client's postoperative care, which action is the highest priority?
- A. Providing the client with protein-rich foods
- B. Ambulating the client frequently
- C. Monitoring for wound infection
- D. Assessing for frequent leg cramping
Correct Answer: C
Rationale: Monitoring for wound infection is critical post-surgery to prevent complications and ensure healing.
The nurse is assessing a client with heart failure. Which finding indicates worsening condition?
- A. Weight gain of 3 pounds in 2 days
- B. Blood pressure of 120/80 mmHg
- C. Heart rate of 70 beats per minute
- D. Clear lung sounds bilaterally
Correct Answer: A
Rationale: Rapid weight gain in heart failure indicates fluid retention, a sign of worsening condition.