Nokea
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.
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The client tells the nurse that his cholesterol level is 240 mg/dL. Which action should the nurse implement?
- A. Praise the client for having a normal cholesterol level.
- B. Explain that the client needs to lower the cholesterol level.
- C. Discuss dietary changes that could help increase the level.
- D. Allow the client to ventilate feelings about the blood test result.
Correct Answer: B
Rationale: Cholesterol 240 mg/dL (B) is high (>200 is abnormal), requiring education to lower it. Praising (A) is incorrect, increasing (C) is harmful, and venting (D) is secondary.
The nurse is preparing to administer 7.5 mg of an oral anticoagulant. The medication available is 5 mg per tablet. How many tablets should the nurse administer?
Correct Answer: 1.5
Rationale: Dose required: 7.5 mg. Available: 5 mg/tablet. 7.5 ÷ 5 = 1.5 tablets. Administer 1.5 tablets (e.g., one whole and one half, if scored).
The client had an abdominal aortic aneurysm repair two (2) days ago. Which intervention should the nurse implement first?
- A. Assess the client’s bowel sounds.
- B. Administer an IV prophylactic antibiotic.
- C. Encourage the client to splint the incision.
- D. Ambulate the client in the room with assistance.
Correct Answer: A
Rationale: Assessing bowel sounds (A) is first to detect ileus, common post-AAA repair. Antibiotics (B), splinting (C), and ambulation (D) follow based on assessment.
The client is prescribed nitroglycerin for angina. Which instruction should the nurse include?
- A. Take it every day even if you feel well.
- B. Place the tablet under your tongue.
- C. Swallow the tablet with water.
- D. Apply it as a patch on your chest.
Correct Answer: B
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption to relieve angina.
The nurse has just received the a.m. shift report. Which client would the nurse assess first?
- A. The client with a venous stasis ulcer who is complaining of pain.
- B. The client with varicose veins who has dull, aching muscle cramps.
- C. The client with arterial occlusive disease who cannot move the foot.
- D. The client with deep vein thrombosis who has a positive Homans’ sign.
Correct Answer: C
Rationale: Inability to move the foot in arterial disease (C) suggests acute ischemia, a priority. Ulcer pain (A), cramps (B), and Homans’ sign (D) are less urgent.