Nokea
The client with varicose veins is six (6) hours postoperative vein ligation. Which nursing intervention should the nurse implement first?
- A. Assist the client to dangle the legs off the side of the bed.
- B. Assess and maintain pressure bandages on the affected leg.
- C. Apply a sequential compression device to the affected leg.
- D. Administer the prescribed prophylactic intravenous antibiotic.
Correct Answer: B
Rationale: Assessing/maintaining pressure bandages (B) prevents bleeding post-vein ligation. Dangling (A) is premature, compression devices (C) are secondary, and antibiotics (D) follow assessment.
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Which activity should the nurse advise a client with cardiomyopathy to avoid?
- A. Walking at a moderate pace
- B. Heavy weightlifting
- C. Swimming for 20 minutes
- D. Yoga with gentle stretches
Correct Answer: B
Rationale: Heavy weightlifting increases cardiac strain, which is dangerous in cardiomyopathy.
Which assessment finding in a client with a pacemaker requires immediate action? Select all that apply.
- A. Heart rate of 50 beats per minute
- B. Pain at the insertion site
- C. Fever of 101°F
- D. Hiccups that persist
- E. Swelling at the pacemaker site
- F. Mild bruising at the site
Correct Answer: A,C,D,E
Rationale: Low heart rate, fever, persistent hiccups, and swelling suggest pacemaker malfunction or infection, requiring immediate attention.
The client is prescribed amiodarone for an arrhythmia. Which side effect should the nurse teach the client to report?
- A. Mild nausea
- B. Blue-gray skin discoloration
- C. Increased appetite
- D. Dry mouth
Correct Answer: B
Rationale: Blue-gray skin discoloration is a serious side effect of amiodarone, indicating potential toxicity.
Which client behavior would be a causative factor for developing Buerger's disease (thromboangiitis obliterans)?
- A. Drinking alcohol daily.
- B. Eating a high-fat diet.
- C. Chewing tobacco.
- D. Inhaling gasoline fumes.
Correct Answer: C
Rationale: Buerger’s disease is strongly linked to tobacco use, including chewing tobacco (C), which causes vascular inflammation. Alcohol (A), high-fat diet (B), and gasoline fumes (D) are not primary causes.
The client with a mechanical heart valve reports a fever. What should the nurse do first?
- A. Administer acetaminophen.
- B. Notify the healthcare provider.
- C. Check the client's temperature again in 4 hours.
- D. Encourage fluid intake.
Correct Answer: B
Rationale: Fever may indicate endocarditis in a client with a mechanical valve, requiring immediate medical evaluation.