Nokea
The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). The nurse should assess the client further for signs of:
- A. Aortic aneurysm
- B. Deep vein thrombosis (DVT) in the left leg
- C. I.V. drug abuse
- D. Intermittent claudication
Correct Answer: B
Rationale: Left leg pain, positive Homans' sign (pain on dorsiflexion), and low-grade fever suggest deep vein thrombosis (DVT). Further assessment for swelling, redness, or warmth confirms this. Aortic aneurysm, I.V. drug abuse, and claudication present differently.
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A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by:
- A. Showing the location of the obstruction and the collateral circulation
- B. Scanning the affected extremity and identifying the areas of volume changes
- C. Using ultrasound to estimate the velocity change in the blood vessels
- D. Determining how long the client can walk
Correct Answer: A
Rationale: An arteriogram involves injecting contrast dye to visualize arteries, revealing the location of obstructions and collateral circulation in occlusive arterial disease. It is a direct imaging method, unlike ultrasound (velocity changes) or volume scans, and walking duration is not assessed.
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.
The nurse should instruct the client with an ileostomy to report which of the following signs and symptoms immediately?
- A. Passage of liquid stool from the stoma.
- B. Occasional presence of undigested food in the effluent.
- C. Absence of drainage from the ileostomy for 6 or more hours.
- D. Temperature of 99.8°F (37.7°C).
Correct Answer: C
Rationale: Absence of drainage from an ileostomy for 6 or more hours may indicate a blockage, requiring immediate reporting. Liquid stool and undigested food are normal, and a slightly elevated temperature is less urgent unless persistent. CN: Physiological adaptation; CL: Synthesize
The newly hired nurse cares for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up by the charge nurse?
- A. Applying a tourniquet proximal to the bite.
- B. Removing the client's wristwatch and jewelry.
- C. Establishing intravenous (IV) access.
- D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).
Correct Answer: A
Rationale: Applying a tourniquet can worsen tissue damage by restricting blood flow and concentrating venom, requiring follow-up. Removing jewelry (B) prevents constriction from swelling, establishing IV access (C) is essential for antivenom administration, and type and crossmatch (D) may be appropriate for potential complications.
Which of the following changes are associated with normal aging?
- A. The outer layer of skin is replaced with new cells every 3 days.
- B. Subcutaneous fat and extracellular water decrease.
- C. The dermis becomes highly vascular and assists in the regulation of body temperature.
- D. Collagen becomes elastic and strong.
Correct Answer: B
Rationale: Aging reduces subcutaneous fat and extracellular water, leading to thinner, drier skin. Cell replacement slows, vascularity decreases, and collagen loses elasticity.