Nokea
The client has midcalf pain when walking a block or more. The client states that the discomfort is relieved with rest. The pain is expected when arterial occlusion reaches which of the following percentages?
- A. 20%
- B. 40%
- C. 50%
- D. 100%
Correct Answer: C
Rationale: Claudication typically occurs when arterial occlusion reaches approximately 50%, significantly reducing blood flow to muscles during activity. This causes ischemia and pain, which is relieved by rest when oxygen demand decreases. Complete (100%) occlusion would cause rest pain or tissue necrosis, not just claudication.
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A client receiving TPN reports sudden chest pain and dyspnea. Which action should the nurse take first?
- A. Stop the TPN infusion.
- B. Administer oxygen as ordered.
- C. Notify the physician.
- D. Check the client's blood glucose.
Correct Answer: C
Rationale: Sudden chest pain and dyspnea in a client receiving TPN may indicate a serious complication like an air embolism or infection, requiring immediate physician notification. Stopping the infusion or checking glucose is premature, and oxygen requires an order. CN: Physiological adaptation; CL: Synthesize
A nurse is caring for a client with a central venous catheter (CVC) in place. Which action by the nurse is most effective in preventing central line-associated bloodstream infections (CLABSI)?
- A. Performing hand hygiene before and after any manipulation of the CVC.
- B. Monitoring the client's temperature every 4 hours.
- C. Administering prophylactic antibiotics.
- D. Ensuring the client maintains strict bed rest to prevent catheter movement.
Correct Answer: A
Rationale: Hand hygiene is the most effective measure to prevent CLABSI by reducing microbial contamination.
A health care provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames?
- A. 5 minutes.
- B. 10 minutes.
- C. 20 minutes.
- D. 30 minutes.
Correct Answer: C
Rationale: Protamine sulfate neutralizes heparin rapidly, with effects typically seen within 20 minutes of administration. This allows for quick reversal of heparin's anticoagulant effects in cases of bleeding. The other time frames are either too short or too long.
The nurse is teaching the client and family how to manage possible nausea and vomiting at home. The nurse should include information about:
- A. Eating frequent, small meals throughout the day.
- B. Eating three normal meals a day.
- C. Eating only cold foods with no odor.
- D. Limiting the amount of fluid intake.
Correct Answer: A
Rationale: Eating frequent, small meals helps prevent nausea by avoiding an empty or overly full stomach, which can trigger vomiting during chemotherapy.
The nurse is teaching a client about managing osteoarthritis pain. Which non-pharmacologic intervention should be included?
- A. Apply ice packs for 30 minutes at a time.
- B. Maintain a high-protein diet.
- C. Use a heating pad on high setting.
- D. Perform gentle range-of-motion exercises.
Correct Answer: D
Rationale: Gentle range-of-motion exercises maintain joint mobility and reduce stiffness in osteoarthritis.