Nokea
The client with vasospastic disorder (Raynaud's phenomenon) complains of cold and numbness in her fingers. The nurse assesses the client for effects of vasoconstriction. Which of the following is an early sign of vasoconstriction?
- A. Cyanosis
- B. Gangrene
- C. Pallor
- D. Rubor
Correct Answer: C
Rationale: Pallor is an early sign of vasoconstriction in Raynaud's, as reduced blood flow causes the skin to turn white. Cyanosis occurs later with prolonged ischemia, gangrene is a late complication, and rubor (redness) occurs during the hyperemic phase after vasospasm resolves.
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During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she visits an invalid friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client prevent this problem?
- A. Visit her friend early in the day.
- B. Rest for at least an hour before climbing the stairs.
- C. Take a nitroglycerin tablet before climbing the stairs.
- D. Lie down once she reaches the friend's apartment.
Correct Answer: C
Rationale: Taking sublingual nitroglycerin before exertion (e.g., climbing stairs) prevents angina by dilating coronary arteries, increasing myocardial oxygen supply.
A client who underwent a left lower lobectomy has been out of surgery for 48 hours. She is receiving morphine sulfate via a patient-controlled analgesia (PCA) system. She tells the nurse that she has some pain in her left thorax that worsens when she coughs. The nurse should:
- A. I don't be silent, so that she is not stimulated to cough.
- B. Encourage the client to take deep breaths to help control the pain.
- C. Check that the PCA device is functioning properly, and then reassure the client that the machine is working and will relieve her pain.
- D. Obtain a more detailed assessment of the client's pain using a pain scale.
Correct Answer: D
Rationale: A detailed pain assessment using a scale clarifies the pain's severity and guides adjustments to analgesia. Silencing the client or encouraging deep breaths may worsen pain. Checking the PCA is appropriate but secondary to assessment.
A client who is scheduled for an open cholecystectomy has a 20-pack-year history of smoking. For which postoperative complication is the client most at risk?
- A. Deep vein thrombosis.
- B. Atelectasis and pneumonia.
- C. Delayed wound healing.
- D. Prolonged immobility.
Correct Answer: B
Rationale: Smoking impairs lung function and ciliary clearance, increasing the risk of atelectasis and pneumonia post-surgery due to reduced lung expansion and mucus clearance.
A client on hemodialysis reports fatigue. The nurse should assess for:
- A. Anemia.
- B. Hyperkalemia.
- C. Dehydration.
- D. Infection.
Correct Answer: A
Rationale: Anemia is common in renal failure due to decreased erythropoietin.
When beginning I.V. erythropoietin (Epogen, Procrit) therapy, the nurse should do which of the following? Select all that apply.
- A. Checking the hemoglobin levels before administering subsequent doses.
- B. Shaking the vial thoroughly to mix the concentrated white, milky solution.
- C. Keeping the multidose vial refrigerated between scheduled twice-a-day doses.
- D. Administering the medication through the I.V. line without other medications.
- E. Adjusting the initial doses according to the client's changes in blood pressure.
- F. Educating the client to avoid driving and performing hazardous activity during the initial treatment.
Correct Answer: A,C,D,F
Rationale: For IV erythropoietin therapy, the nurse should check hemoglobin levels to monitor response and prevent overcorrection, keep multidose vials refrigerated to maintain stability, administer without mixing with other medications to avoid interactions, and educate about avoiding hazardous activities due to potential side effects like dizziness. Shaking the vial can denature the protein, and dose adjustments are typically based on hematologic response, not blood pressure.