Nokea
The nurse has just received the a.m. shift report. Which client would the nurse assess first?
- A. The client with a venous stasis ulcer who is complaining of pain.
- B. The client with varicose veins who has dull, aching muscle cramps.
- C. The client with arterial occlusive disease who cannot move the foot.
- D. The client with deep vein thrombosis who has a positive Homans’ sign.
Correct Answer: C
Rationale: Inability to move the foot in arterial disease (C) suggests acute ischemia, a priority. Ulcer pain (A), cramps (B), and Homans’ sign (D) are less urgent.
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The unlicensed assistive personnel (UAP) is applying elastic compression stockings to the client. Which action by the UAP would warrant immediate intervention by the nurse?
- A. The UAP is putting the stockings on while the client is in the chair.
- B. The UAP inserted two (2) fingers under the proximal end of the stocking.
- C. The UAP elevated the feet while lying down prior to putting on the stockings.
- D. The UAP made sure the toes were warm after putting the stockings on.
Correct Answer: A
Rationale: Applying stockings in a chair (A) is incorrect; legs should be elevated to reduce edema. Two fingers (B) ensures fit, elevation (C) is correct, and warm toes (D) is appropriate.
The nurse is caring for clients on a surgical floor. Which client should be assessed first?
- A. The client who is four (4) days postoperative abdominal surgery and is complaining of left calf pain when ambulating.
- B. The client who is one (1) day postoperative hernia repair who has just been able to void 550 mL of clear amber urine.
- C. The client who is five (5) days postoperative open cholecystectomy who has a T-tube and is being discharged.
- D. The client who is 16 hours post-abdominal hysterectomy and is complaining of abdominal pain and is expelling flatus.
Correct Answer: A
Rationale: Calf pain post-surgery (A) suggests DVT, requiring immediate assessment. Normal voiding (B), discharge (C), and expected pain/flatus (D) are less urgent.
The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which intervention should the nurse implement?
- A. Notify the health-care provider if the potassium level is 3.8 mEq.
- B. Question administering the medication if the BP is less than 90/60 mm Hg.
- C. Do not administer the medication if the client's radial pulse is greater than 100.
- D. Monitor the client's BP while he or she is lying, standing, and sitting.
Correct Answer: B
Rationale: Beta blockers lower BP; BP <90/60 (B) indicates hypotension, warranting withholding the dose. Potassium 3.8 (A) is normal, pulse >100 (C) is not a contraindication, and orthostatic checks (D) are routine but not primary.
Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency?
- A. Decreased pedal pulses.
- B. Cool skin temperature.
- C. Intermittent claudication.
- D. Brown discolored skin.
Correct Answer: D
Rationale: Brown discoloration (D) results from hemosiderin deposits in venous insufficiency. Decreased pulses (A) and claudication (C) are arterial, and cool skin (B) is not typical (skin is often warm).
The client diagnosed with essential hypertension asks the nurse, 'I don’t know why the doctor is worried about my blood pressure. I feel just great.' Which statement by the nurse would be the most appropriate response?
- A. Damage can be occurring to your heart and kidneys even if you feel great.'
- B. Unless you have a headache, your blood pressure is probably within normal limits.'
- C. When is the last time you saw your doctor? Does he know you are feeling great?'
- D. Your blood pressure reflects how well your heart is working.'
Correct Answer: A
Rationale: Hypertension causes silent organ damage (heart, kidneys) (A), even without symptoms. Headaches (B) aren’t reliable, doctor visits (C) are irrelevant, and heart function (D) is vague.