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The client is admitted for surgical repair of an 8-cm abdominal aortic aneurysm (AAA). Which sign/symptom would make the nurse suspect the client has an expanding AAA?
- A. Complaints of low back pain.
- B. Weakened radial pulses.
- C. Decreased urine output.
- D. Increased abdominal girth.
Correct Answer: A
Rationale: Low back pain (A) suggests AAA expansion or rupture, a critical sign. Radial pulses (B) are unaffected, low urine (C) is a late sign, and girth (D) is less specific.
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The nurse is assessing a client with pericarditis. Which finding is most characteristic?
- A. Chest pain relieved by leaning forward
- B. Swelling in the ankles
- C. Fever above 103°F
- D. Bradycardia
Correct Answer: A
Rationale: Pericarditis causes chest pain that is typically relieved by leaning forward, reducing pressure on the inflamed pericardium.
Which actions should the surgical scrub nurse take to prevent personally developing a DVT?
- A. Keep the legs in a dependent position and stand as still as possible.
- B. Flex the leg muscles and change the leg positions frequently.
- C. Wear white socks and shoes that have an elevated heel.
- D. Ask the surgeon to allow the nurse to take a break midway through each surgery.
Correct Answer: B
Rationale: Flexing muscles and changing positions (B) promote venous return, preventing DVT. Dependent position (A) increases risk, socks/heels (C) are irrelevant, and breaks (D) are impractical.
Which complication should the nurse monitor for in a client with valvular heart disease?
- A. Pulmonary embolism
- B. Heart failure
- C. Liver failure
- D. Pneumonia
Correct Answer: B
Rationale: Valvular heart disease can lead to heart failure due to increased cardiac workload and impaired pump function.
The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?
- A. The client's BP is 110/70.
- B. The client's potassium level is 3.4 mEq/L.
- C. The client has a barky cough.
- D. The client's apical pulse is 56.
Correct Answer: D
Rationale: Beta blockers slow heart rate; an apical pulse of 56 (D) may indicate bradycardia, warranting caution. BP 110/70 (A) is acceptable, K+ 3.4 (B) is low but unrelated, and cough (C) is not a contraindication.
The nurse is caring for a client who is receiving heparin therapy intravenously. Which assessment data would indicate to the nurse the client is developing heparin-induced thrombocytopenia (HIT)? Select all that apply.
- A. The client has spontaneous bleeding from around the IV site.
- B. The client complains of chest pain on inspiration and has become restless.
- C. The client’s platelet count on admission was 420 (103) and now is 200 (103).
- D. The client complains that the gums bleed when brushing the teeth.
- E. The client has developed skin lesions at the IV site.
Correct Answer: A,C,D
Rationale: HIT causes thrombocytopenia and bleeding: IV site bleeding (A), platelet drop from 420 to 200 (C), and gum bleeding (D) are signs. Chest pain/restlessness (B) suggests PE, and skin lesions (E) are not typical.