Nokea
The client is diagnosed with a small abdominal aortic aneurysm. Which interventions should be included in the discharge teaching? Select all that apply.
- A. Tell the client to exercise three (3) times a week for 30 minutes.
- B. Encourage the client to eat a low-fat, low-cholesterol diet.
- C. Instruct the client to decrease tobacco use.
- D. Discuss the importance of losing weight with the client.
- E. Teach the client to wear a truss at all times.
Correct Answer: A,B,C,D
Rationale: Exercise (A), low-fat diet (B), smoking reduction (C), and weight loss (D) reduce AAA progression. Trusses (E) are irrelevant to AAA management.
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The nurse is admitting a client diagnosed with peripheral vascular disease. Which data support a diagnosis of venous insufficiency?
- A. The client has bright red skin on the lower extremities.
- B. The client has a brownish purple area on the lower legs.
- C. The client complains of pain after ambulating for short distances.
- D. The client has nonhealing wounds on the toes and ankles.
Correct Answer: B
Rationale: Brownish purple skin (B) indicates hemosiderin from venous stasis. Red skin (A) is nonspecific, pain with walking (C) is arterial, and toe/ankle wounds (D) are arterial.
The nurse is monitoring a client post-percutaneous coronary intervention (PCI). Which finding requires immediate action?
- A. Heart rate of 80 beats per minute
- B. Bleeding at the catheter site
- C. Blood pressure of 130/85 mmHg
- D. Mild discomfort at the insertion site
Correct Answer: B
Rationale: Bleeding at the catheter site can indicate a hematoma or hemorrhage, requiring immediate intervention.
The client diagnosed with arterial occlusive disease is one (1) day postoperative right femoral-popliteal bypass. Which intervention should the nurse implement?
- A. Keep the right leg in the dependent position.
- B. Apply sequential compression devices to lower extremities.
- C. Monitor the client's pedal pulses every shift.
- D. Assess the client's leg dressing every four (4) hours.
Correct Answer: C
Rationale: Monitoring pedal pulses (C) assesses graft patency post-bypass, critical to ensure circulation. Dependent position (A) impairs flow, compression devices (B) are for venous issues, and dressing checks (D) are routine but secondary.
The client with a mechanical heart valve reports a fever. What should the nurse do first?
- A. Administer acetaminophen.
- B. Notify the healthcare provider.
- C. Check the client's temperature again in 4 hours.
- D. Encourage fluid intake.
Correct Answer: B
Rationale: Fever may indicate endocarditis in a client with a mechanical valve, requiring immediate medical evaluation.
The client diagnosed with a deep vein thrombosis (DVT) is prescribed a heparin drip. The solution is 40,000 units in 500 mL of D5W. The health-care provider ordered the client to receive 1,200 units per hour. At which rate should the nurse set the IV pump?
Correct Answer: 15
Rationale: Heparin concentration: 40,000 units/500 mL = 80 units/mL. Dose: 1,200 units/hr ÷ 80 units/mL = 15 mL/hr. Set pump to 15 mL/hr.