Nokea
The client is being ambulated due to activity intolerance caused by bacterial endocarditis. How can the nurse determine that the client is best tolerating ambulation?
- A. Mild dyspnea after walking 10 feet
- B. Minimal chest pain rated 1 on a 1-to-10 pain scale
- C. Pulse rate that increases from 68 to 94 beats per minute
- D. Blood pressure that increases from 114/82 to 118/86 mm Hg
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with a history of angina is scheduled for an exercise electrocardiography (ECG) test. The nurse should explain that the purpose of this test is to evaluate which factor?
- A. The heart's response to physical stress
- B. The client's overall physical fitness
- C. The presence of electrolyte imbalances
- D. The effectiveness of anti-anginal medications
Correct Answer: A
Rationale: An exercise electrocardiography (ECG) test is used to evaluate the heart's response to physical stress. During the test, the heart's electrical activity is monitored while the client exercises, helping to identify any areas of ischemia or abnormal rhythms. This test helps healthcare providers assess the heart's function and detect any potential issues related to angina or other cardiac conditions.
A client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned, knowing that this level could lead to which complication?
- A. Stroke
- B. Cardiac arrest
- C. High blood pressure
- D. Urinary stone formation
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation?
- A. The ulcer has a pale-colored base.
- B. The ulcer is deep, with even edges.
- C. The ulcer has little granulation tissue.
- D. The ulcer has a brownish or 'brawny' appearance.
Correct Answer: D
Rationale: When assessing a venous stasis leg ulcer, the nurse should expect to note a brownish or 'brawny' appearance. This discoloration is often due to hemosiderin deposits. This characteristic finding helps differentiate venous stasis ulcers from other types of ulcers, making it crucial for accurate diagnosis and appropriate treatment.
The client with Raynaud's phenomenon is being taught by the nurse about preventing episodes. Which instruction should the nurse reinforce?
- A. Wear gloves in cold weather.
- B. Avoid caffeine and chocolate.
- C. Increase intake of vitamin C.
- D. Use a heating pad for warmth.
Correct Answer: A
Rationale: Wearing gloves in cold weather is essential for preventing vasoconstriction and subsequent episodes of Raynaud's phenomenon. Cold temperatures can trigger vasospasms in individuals with Raynaud's, and wearing gloves helps maintain warmth and prevent the constriction of blood vessels in the extremities, reducing the likelihood of an episode.
A client with peripheral arterial disease complains of leg pain while walking. The nurse should reinforce which teaching point with the client?
- A. Wear compression stockings daily.
- B. Increase daily walking distance gradually.
- C. Elevate legs above heart level when resting.
- D. Use a heating pad to soothe leg muscles.
Correct Answer: B
Rationale: For clients with peripheral arterial disease experiencing leg pain while walking, gradually increasing daily walking distance is beneficial. This approach helps improve circulation, build tolerance, and reduce symptoms over time. Compression stockings can also be recommended for some clients to assist with circulation, but the priority teaching point in this scenario is to promote gradual increases in walking distance to enhance vascular health and symptom management.