Nokea
The client with an arterial disorder reports cold feet. Which action should the nurse take first?
- A. Apply warm blankets to the feet.
- B. Check the pedal pulses bilaterally.
- C. Elevate the feet above heart level.
- D. Massage the feet to improve circulation.
Correct Answer: B
Rationale: Checking pedal pulses assesses arterial perfusion, which is critical in determining the cause of cold feet in arterial disorders.
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Which finding in a client post-myocardial infarction requires immediate action?
- A. Chest pain lasting 20 minutes
- B. Heart rate of 85 beats per minute
- C. Blood pressure of 135/90 mmHg
- D. Mild anxiety
Correct Answer: A
Rationale: Prolonged chest pain post-myocardial infarction may indicate reinfarction or ischemia, requiring immediate intervention.
Which complication of uncontrolled hypertension should the nurse include in client teaching? Select all that apply.
- A. Stroke
- B. Kidney failure
- C. Heart attack
- D. Liver cirrhosis
- E. Vision loss
- F. Peripheral neuropathy
Correct Answer: A,B,C,E
Rationale: Uncontrolled hypertension can damage blood vessels, leading to stroke, kidney failure, heart attack, and vision loss.
The client is admitted for surgical repair of an 8-cm abdominal aortic aneurysm (AAA). Which sign/symptom would make the nurse suspect the client has an expanding AAA?
- A. Complaints of low back pain.
- B. Weakened radial pulses.
- C. Decreased urine output.
- D. Increased abdominal girth.
Correct Answer: A
Rationale: Low back pain (A) suggests AAA expansion or rupture, a critical sign. Radial pulses (B) are unaffected, low urine (C) is a late sign, and girth (D) is less specific.
The client with heart failure is prescribed digoxin. Which finding should the nurse report immediately?
- A. Heart rate of 58 beats per minute
- B. Potassium level of 3.2 mEq/L
- C. Blood pressure of 130/85 mmHg
- D. Respiratory rate of 18 breaths per minute
Correct Answer: B
Rationale: Hypokalemia (low potassium) increases the risk of digoxin toxicity, requiring immediate reporting.
The intensive care department nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 880 mL of D5W, IVPB of 100 mL of 0.9% NS, 8 ounces of water, 4 ounces of milk, and 6 ounces of chicken broth. The client has had a urinary output of 1,480 mL. What is the total intake for this client?
Correct Answer: 1180
Rationale: Total intake = IV fluids (880 mL D5W + 100 mL NS) + oral fluids (8 oz water + 4 oz milk + 6 oz broth). 1 oz = 30 mL, so oral = (8+4+6) × 30 = 540 mL. Total = 880 + 100 + 540 = 1,180 mL. Output (1,480 mL) is not included in intake.