Nokea
The client diagnosed with subclavian steal syndrome has undergone surgery. Which assessment data would warrant immediate intervention by the nurse?
- A. The client’s pedal pulse on the left leg is absent.
- B. The client complains of numbness in the right hand.
- C. The client’s brachial pulse is strong and bounding.
- D. The client’s capillary refill time (CRT) is less than three (3) seconds.
Correct Answer: B
Rationale: Numbness in the right hand (B) post-subclavian surgery suggests nerve or vascular compromise, requiring immediate action. Absent pedal pulse (A) is unrelated, strong brachial pulse (C) is normal, and CRT <3 sec (D) is normal.
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The nurse is preparing a client for valve replacement surgery. Which preoperative teaching is most important?
- A. You will need lifelong anticoagulant therapy.
- B. You can resume heavy lifting in 2 weeks.
- C. You will not need antibiotics before dental procedures.
- D. You should avoid all physical activity post-surgery.
Correct Answer: A
Rationale: Lifelong anticoagulation is often required post-valve replacement to prevent clot formation.
Which intervention should the nurse prioritize for a client with ventricular tachycardia?
- A. Administer lidocaine as prescribed.
- B. Check blood pressure.
- C. Encourage deep breathing.
- D. Apply oxygen at 2 L/min.
Correct Answer: A
Rationale: Lidocaine is used to suppress ventricular tachycardia, a life-threatening arrhythmia.
Which instruction should the nurse include for a client with heart failure to monitor fluid status?
- A. Check blood pressure twice daily.
- B. Weigh yourself every morning.
- C. Record urine color daily.
- D. Measure abdominal girth weekly.
Correct Answer: B
Rationale: Daily weight monitoring detects fluid retention early, as 1 liter of fluid equals approximately 2.2 pounds.
The nurse has just received the a.m. shift report. Which client would the nurse assess first?
- A. The client with a venous stasis ulcer who is complaining of pain.
- B. The client with varicose veins who has dull, aching muscle cramps.
- C. The client with arterial occlusive disease who cannot move the foot.
- D. The client with deep vein thrombosis who has a positive Homans’ sign.
Correct Answer: C
Rationale: Inability to move the foot in arterial disease (C) suggests acute ischemia, a priority. Ulcer pain (A), cramps (B), and Homans’ sign (D) are less urgent.
The client is prescribed nitroglycerin for angina. Which instruction should the nurse include?
- A. Take it every day even if you feel well.
- B. Place the tablet under your tongue.
- C. Swallow the tablet with water.
- D. Apply it as a patch on your chest.
Correct Answer: B
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption to relieve angina.