Nokea
The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change. Which is the nurse’s priority intervention?
- A. Escort the client to the physical therapy department.
- B. Medicate the client 30 minutes before going to the whirlpool.
- C. Obtain the sterile dressing supplies for the client.
- D. Assist the client to the bathroom prior to the treatment.
Correct Answer: B
Rationale: Pain management with medication 30 minutes prior (B) ensures comfort during whirlpool therapy for venous disease. Escorting (A), supplies (C), and bathroom (D) are secondary.
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The client with endocarditis is at risk for which complication?
- A. Embolism
- B. Hypoglycemia
- C. Osteoarthritis
- D. Pancreatitis
Correct Answer: A
Rationale: Endocarditis can cause vegetations on heart valves, which may break off and form emboli.
The health-care provider prescribes an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with essential hypertension. Which statement is the most appropriate rationale for administering this medication?
- A. ACE inhibitors prevent beta receptor stimulation in the heart.
- B. This medication blocks the alpha receptors in the vascular smooth muscle.
- C. ACE inhibitors prevent vasoconstriction and sodium and water retention.
- D. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle.
Correct Answer: C
Rationale: ACE inhibitors block angiotensin II, preventing vasoconstriction and sodium/water retention (C), thus lowering BP. Beta (A) and alpha (B) receptors are unrelated, and smooth muscle relaxation (D) is a secondary effect.
Which teaching point should the nurse include for a client with peripheral artery disease? Select all that apply.
- A. Inspect feet daily for sores or injuries.
- B. Wear tight shoes to support the feet.
- C. Stop smoking to improve blood flow.
- D. Exercise until pain occurs, then rest.
- E. Apply lotion to dry skin on legs.
- F. Avoid crossing legs when sitting.
Correct Answer: A,C,D,E,F
Rationale: Inspecting feet, stopping smoking, exercising with rest, applying lotion, and avoiding leg crossing promote circulation and prevent complications in peripheral artery disease.
The nurse is teaching a client with pericarditis about activity restrictions. Which instruction is most appropriate?
- A. Resume normal activity immediately.
- B. Rest and avoid strenuous activity.
- C. Engage in high-intensity exercise.
- D. Lift heavy objects to build strength.
Correct Answer: B
Rationale: Rest prevents exacerbation of pericardial inflammation and promotes healing.
The nurse is admitting a client diagnosed with peripheral vascular disease. Which data support a diagnosis of venous insufficiency?
- A. The client has bright red skin on the lower extremities.
- B. The client has a brownish purple area on the lower legs.
- C. The client complains of pain after ambulating for short distances.
- D. The client has nonhealing wounds on the toes and ankles.
Correct Answer: B
Rationale: Brownish purple skin (B) indicates hemosiderin from venous stasis. Red skin (A) is nonspecific, pain with walking (C) is arterial, and toe/ankle wounds (D) are arterial.