Nokea
The client presents to the outpatient clinic complaining of calf pain. The client reports returning from an airplane trip the previous day. Which should the nurse assess first?
- A. The nurse should auscultate the lung fields and heart sounds.
- B. The nurse should determine the length of the airplane trip.
- C. The nurse should determine if the client has had chest pain.
- D. The nurse should measure the calf and palpate the calf for warmth.
Correct Answer: C
Rationale: Calf pain post-flight suggests DVT; assessing for chest pain (C) rules out pulmonary embolism, a priority. Lung/heart sounds (A), trip length (B), and calf exam (D) follow.
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The client with peripheral artery disease asks why they need to walk daily. What is the best response?
- A. It strengthens your leg muscles.
- B. It promotes collateral circulation.
- C. It reduces swelling in your legs.
- D. It prevents venous ulcers.
Correct Answer: B
Rationale: Walking stimulates the development of collateral vessels, improving blood flow in peripheral artery disease.
Which should the nurse include in the plan of care for a client diagnosed with venous stasis ulcers? Select all that apply.
- A. Elevate the legs while sitting.
- B. Wear antiembolism compression stockings.
- C. Avoid injury to the lower limbs.
- D. Trim the toenails straight across.
- E. Do not apply moisturizer to the lower legs.
- F. Allow the legs to hang over the bed in a dependent position.
Correct Answer: A,B,C,D
Rationale: Leg elevation (A), compression stockings (B), injury avoidance (C), and straight toenail trimming (D) manage venous ulcers. Moisturizer (E) is beneficial, and dependent position (F) worsens edema.
The nurse identifies the concept of clotting for a client diagnosed with a deep vein thrombosis. Which clinical manifestations support the diagnosis?
- A. Brown-purple discoloration on the calf.
- B. Bright red skin on the lower legs.
- C. Swelling in the calf, warmth, and tenderness.
- D. Pain after walking for short distances that resolve with rest.
Correct Answer: C
Rationale: Swelling, warmth, and tenderness (C) are classic DVT signs. Brown-purple (A) is venous insufficiency, red skin (B) is nonspecific, and pain with walking (D) is arterial.
The client with hypertension reports dizziness when standing. What should the nurse assess first?
- A. Blood glucose level
- B. Orthostatic blood pressure
- C. Urine output
- D. Respiratory rate
Correct Answer: B
Rationale: Dizziness when standing suggests orthostatic hypotension, which should be confirmed by measuring blood pressure in lying, sitting, and standing positions.
The client with a pacemaker asks how to check if it is working. What is the best response?
- A. Check your pulse regularly.
- B. Monitor your blood pressure daily.
- C. Weigh yourself every morning.
- D. Measure your temperature daily.
Correct Answer: A
Rationale: Checking the pulse ensures the pacemaker is maintaining an appropriate heart rate.