Nokea
The client is four (4) hours postoperative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?
- A. Assist the client to ambulate.
- B. Assess the client's bilateral pedal pulses.
- C. Maintain a continuous IV heparin drip.
- D. Provide a clear liquid diet to the client.
Correct Answer: B
Rationale: Assessing pedal pulses (B) monitors graft patency post-AAA repair, critical at 4 hours. Ambulation (A) is premature, heparin (C) is not routine, and diet (D) awaits bowel function.
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The client diagnosed with peripheral vascular disease is overweight, has smoked two (2) packs of cigarettes a day for 20 years, and sits behind a desk all day. What is the strongest factor in the development of atherosclerotic lesions?
- A. Being overweight.
- B. Sedentary lifestyle.
- C. High-fat, high-cholesterol diet.
- D. Smoking cigarettes.
Correct Answer: D
Rationale: Smoking (D) is the strongest risk factor for atherosclerosis, causing endothelial damage and plaque formation. Obesity (A), sedentary lifestyle (B), and diet (C) contribute but are less potent.
Which arterial anticoagulant medication would the nurse anticipate being prescribed for a client diagnosed with arterial occlusive disease?
- A. Clopidogrel.
- B. Streptokinase.
- C. Protamine sulfate.
- D. Enoxaparin.
Correct Answer: A
Rationale: Clopidogrel (A), an antiplatelet, is used in arterial occlusive disease to prevent thrombosis. Streptokinase (B) is a thrombolytic, protamine (C) reverses heparin, and enoxaparin (D) is for DVT.
Which teaching point should the nurse include for a client with heart failure?
- A. Avoid all physical activity.
- B. Report weight gain of 2 pounds or more in a day.
- C. Take extra diuretics if you feel short of breath.
- D. Eat high-sodium foods to maintain electrolytes.
Correct Answer: B
Rationale: Rapid weight gain indicates fluid retention, requiring prompt reporting to manage heart failure.
The client with hypertension asks why they need to limit stress. What is the best response?
- A. Stress causes fluid retention.
- B. Stress increases your heart rate and blood pressure.
- C. Stress reduces oxygen to your heart.
- D. Stress weakens your immune system.
Correct Answer: B
Rationale: Stress activates the sympathetic nervous system, increasing heart rate and blood pressure.
The nurse is preparing a client for a cardiac catheterization. Which pre-procedure instruction is most important?
- A. You will be sedated during the procedure.
- B. You must fast for 6-8 hours before the test.
- C. You can drive home after the procedure.
- D. You should avoid taking aspirin before the test.
Correct Answer: B
Rationale: Fasting prevents aspiration during sedation and ensures accurate test results.