Nokea
The client with varicose veins asks the nurse, 'What caused me to have these?' Which statement by the nurse would be most appropriate?
- A. You have incompetent valves in your legs.'
- B. Your legs have decreased oxygen to the muscle.'
- C. There is an obstruction in the saphenous vein.'
- D. Your blood is thick and can’t circulate properly.'
Correct Answer: A
Rationale: Varicose veins result from incompetent venous valves (A), causing pooling. Low oxygen (B) is arterial, obstruction (C) is not typical, and thick blood (D) is incorrect.
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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 assessing a client with heart failure. Which finding indicates worsening condition?
- A. Weight gain of 3 pounds in 2 days
- B. Blood pressure of 120/80 mmHg
- C. Heart rate of 70 beats per minute
- D. Clear lung sounds bilaterally
Correct Answer: A
Rationale: Rapid weight gain in heart failure indicates fluid retention, a sign of worsening condition.
The client is one (1) day postoperative abdominal aortic aneurysm repair. Which information from the unlicensed assistive personnel (UAP) would require immediate intervention from the nurse?
- A. The client refuses to turn from the back to the side.
- B. The client’s urinary output is 90 mL in six (6) hours.
- C. The client wants to sit on the side of the bed.
- D. The client’s vital signs are T 98, P 90, R 18, and BP 130/70.
Correct Answer: B
Rationale: Urine output of 90 mL in 6 hours (B) (<30 mL/hr) suggests renal compromise, requiring immediate intervention. Refusing to turn (A), sitting (C), and normal vitals (D) are less urgent.
The client diagnosed with peripheral vascular disease is overweight, has smoked two (2) packs of cigarettes a day for 20 years, and sits behind a desk all day. What is the strongest factor in the development of atherosclerotic lesions?
- A. Being overweight.
- B. Sedentary lifestyle.
- C. High-fat, high-cholesterol diet.
- D. Smoking cigarettes.
Correct Answer: D
Rationale: Smoking (D) is the strongest risk factor for atherosclerosis, causing endothelial damage and plaque formation. Obesity (A), sedentary lifestyle (B), and diet (C) contribute but are less potent.
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.