Nokea
The client with Raynaud’s disease is seen in a vascular clinic 6 weeks after nifedipine has been prescribed. The nurse evaluates that the medication has been effective when which findings are noted?
- A. The client’s blood pressure is 110/68 mm Hg.
- B. The client states experiencing less pain and numbness.
- C. The client states that tolerance to heat is improved.
- D. The client walks without intermittent claudication
Correct Answer: B
Rationale: Raynaud’s disease is a disease in which cutaneous arteries in the extremities have recurrent episodes of vasospasm that result in pain and numbness. Nifedipine (Procardia), a calcium-channel blocker, causes vasodilation, thus reducing pain and numbness. BP changes, heat tolerance, and claudication are not primary indicators.
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The nurse is preparing the client for a thoracic aneurysm repair. Which assessment findings should prompt the nurse to conclude that a rupture may have occurred? Select all that apply.
- A. Oliguria
- B. Dyspnea
- C. Hypotension
- D. Abdominal distention
- E. Severe chest pain radiating to the back
Correct Answer: A;B;C;E
Rationale: A rupture may cause: A) Oliguria from decreased renal perfusion; B) Dyspnea from hemorrhage pressure; C) Hypotension from blood loss; E) Severe chest pain radiating to the back. Abdominal distention is associated with abdominal, not thoracic, aneurysms.
The nurse increases activity for the client with an admitting diagnosis of ACS. Which client finding best supports that the client is not tolerating the activity?
- A. Pulse rate increased by 15 beats per minute during activity
- B. BP 130/86 mm Hg before activity; 108/66 mm Hg during activity
- C. Increased dyspnea and diaphoresis relieved when sitting in a chair
- D. A mean arterial pressure (MAP) of 80 following activity
Correct Answer: B
Rationale: A drop in BP of 20 mm Hg from the baseline indicates that the client’s heart is unable to adapt to the increased energy and oxygen demands of the activity. The client is not tolerating the activity; the length of time or the intensity should be reduced. A modest pulse increase, relieved symptoms, and normal MAP are less concerning.
The client states to the clinic nurse, “I had pain in the left calf for a few days earlier in the week, but I am pain free now.” The nurse’s assessment findings include: dorsalis pedis pulses palpable, no pain upon dorsiflexion bilaterally, a few visible varicose veins in each leg, and slight swelling in only the left leg. Which is the nurse’s best action?
- A. Ask if the client has been walking more lately.
- B. Inform the HCP of the assessment findings.
- C. Ask if the client has considered taking a baby aspirin daily.
- D. Explain to the client that there are no significant findings.
Correct Answer: B
Rationale: The nurse should inform the HCP about the assessment findings. A possible DVT is taken seriously because it can lead to PE. Unilateral swelling of one leg is a classic symptom of DVT. Additional questions, aspirin advice, or dismissing findings are inappropriate without further evaluation.
The nurse completes teaching the client with a newly inserted ICD. Which statement, if made by the client, indicates that further teaching is needed?
- A. “The ICD will give me a shock if my heart goes into ventricular fibrillation again.”
- B. “When I feel the first shock, my family should start CPR immediately and call 911.”
- C. “I’m afraid of my first shock; my friend stated his shock felt like a blow to the chest.”
- D. “Some states do not allow driving until there is a 6-month discharge-free period.”
Correct Answer: B
Rationale: CPR should only be initiated if the client is unresponsive and pulseless. EMS should be called if there is more than one shock. This statement indicates further teaching is needed. The other statements are correct regarding ICD function, shock sensation, and driving restrictions.
The client is admitted with an ACS. Which should be the nurse’s priority assessment?
- A. Pain
- B. Blood pressure
- C. Heart rate
- D. Respiratory rate
Correct Answer: A
Rationale: The nurse’s priority assessment in ACS is the client’s pain; pain indicates that the heart is not receiving adequate oxygen and blood flow (perfusion). BP, HR, and RR are secondary as they stem from the lack of perfusion.