Nokea
The nurse and an unlicensed assistive personnel (UAP) are caring for a 64-year-old client who is four (4) hours postoperative bilateral femoral-popliteal bypass surgery. Which nursing task should be delegated to the UAP?
- A. Monitor the continuous passive motion machine.
- B. Assist the client to the bedside commode.
- C. Feed the client the evening meal.
- D. Elevate the foot of the client's bed.
Correct Answer: C
Rationale: Feeding the client (C) is within the UAP’s scope and safe post-bypass. Monitoring CPM (A), assisting to commode (B), and elevating bed (D) require nursing judgment due to circulation concerns.
You may also like to solve these questions
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.
The client diagnosed with Buerger’s disease (thromboangiitis obliterans) asks the nurse, 'What is the worst thing that could happen if I don’t quit smoking? I love my cigarettes.' Which statement is the nurse’s best response?
- A. You are concerned about quitting smoking. Let’s sit down and talk about it.'
- B. Many clients end up having to have an amputation, especially a leg.'
- C. You should consider attending a smoking cessation program.'
- D. Your coronary arteries could block and cause a heart attack.'
Correct Answer: B
Rationale: Smoking worsens Buerger’s, risking severe ischemia and amputation (B). Concern (A) avoids the question, cessation programs (C) are secondary, and heart attack (D) is less specific.
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 the client diagnosed with arterial occlusive disease. Which interventions should the nurse include in the teaching? Select all that apply.
- A. Wash legs and feet daily in warm water.
- B. Apply moisturizing cream to feet.
- C. Buy shoes in the morning hours only.
- D. Do not wear any type of knee stocking.
- E. Wear clean white cotton socks.
Correct Answer: A,B,D,E
Rationale: Washing feet (A), moisturizing (B), avoiding knee stockings (D), and cotton socks (E) prevent skin breakdown and promote circulation in PAD. Morning shoe buying (C) is incorrect; shoes should be bought in the afternoon when feet are larger.
Which finding in a client with mitral stenosis requires immediate action?
- A. Heart rate of 100 beats per minute
- B. New onset of atrial fibrillation
- C. Blood pressure of 140/90 mmHg
- D. Mild fatigue
Correct Answer: B
Rationale: New-onset atrial fibrillation increases the risk of thromboembolism in mitral stenosis, requiring immediate intervention.