Nokea
The client is one (1) day postoperative abdominal aortic aneurysm repair. Which information from the unlicensed assistive personnel (UAP) would require immediate intervention from the nurse?
- A. The client refuses to turn from the back to the side.
- B. The client’s urinary output is 90 mL in six (6) hours.
- C. The client wants to sit on the side of the bed.
- D. The client’s vital signs are T 98, P 90, R 18, and BP 130/70.
Correct Answer: B
Rationale: Urine output of 90 mL in 6 hours (B) (<30 mL/hr) suggests renal compromise, requiring immediate intervention. Refusing to turn (A), sitting (C), and normal vitals (D) are less urgent.
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The client admitted with a diagnosis of pneumonia complains of tenderness and pain in the left calf, and the nurse assesses a positive Homans’ sign. Which interventions should the nurse implement? List in order of priority.
- A. Notify the health-care provider.
- B. Initiate an intravenous line.
- C. Monitor the client’s PTT.
- D. Administer a continuous heparin infusion.
- E. Instruct the client not to get out of the bed.
Correct Answer: A,E,B,D,C
Rationale: 1. Notify HCP (A): Calf pain and positive Homans’ suggest DVT, requiring urgent evaluation. 2. Instruct bedrest (E): Prevents clot dislodgement. 3. Initiate IV (B): Prepares for heparin. 4. Administer heparin (D): Treats DVT post-order. 5. Monitor PTT (C): Ensures therapeutic heparin levels.
The nurse is caring for a client with angina. Which symptom should the nurse expect?
- A. Chest pain relieved by rest
- B. Fever and chills
- C. Swelling in the legs
- D. Persistent dry cough
Correct Answer: A
Rationale: Angina typically presents as chest pain that is relieved by rest due to reduced myocardial oxygen demand.
The nurse is planning care for a client diagnosed with arterial occlusive disease. Which exercise instructions would the nurse teach the client?
- A. Have the client perform isometric exercises 30 minutes each day.
- B. Tell the client to start exercising on a stair stepper for 15 minutes.
- C. Inform the client that warm-up exercises are not necessary.
- D. Teach the client to walk in well-fitting shoes on level ground.
Correct Answer: D
Rationale: Walking on level ground in well-fitting shoes (D) promotes circulation in PAD. Isometric exercises (A) increase BP, stair steppers (B) are too strenuous, and warm-ups (C) are necessary.
Which activity should the nurse advise a client with cardiomyopathy to avoid?
- A. Walking at a moderate pace
- B. Heavy weightlifting
- C. Swimming for 20 minutes
- D. Yoga with gentle stretches
Correct Answer: B
Rationale: Heavy weightlifting increases cardiac strain, which is dangerous in cardiomyopathy.
The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?
- A. Administer intravenous antibiotics.
- B. Apply warm moist packs every two (2) hours.
- C. Elevate the right foot on two (2) pillows.
- D. Teach the client about skin and foot care.
Correct Answer: A
Rationale: Cellulitis requires immediate IV antibiotics (A) to treat infection, especially in diabetes. Warm packs (B), elevation (C), and teaching (D) follow to support healing and prevention.