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The nurse identifies the concept of clotting for a client diagnosed with a deep vein thrombosis. Which clinical manifestations support the diagnosis?
- A. Brown-purple discoloration on the calf.
- B. Bright red skin on the lower legs.
- C. Swelling in the calf, warmth, and tenderness.
- D. Pain after walking for short distances that resolve with rest.
Correct Answer: C
Rationale: Swelling, warmth, and tenderness (C) are classic DVT signs. Brown-purple (A) is venous insufficiency, red skin (B) is nonspecific, and pain with walking (D) is arterial.
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The nurse knows the client understands the teaching concerning a low-fat, low-cholesterol diet when the client selects which meal?
- A. Fried fish, garlic mashed potatoes, and iced tea.
- B. Ham and cheese on white bread and whole milk.
- C. Baked chicken, baked potato, and skim milk.
- D. A hamburger, French fries, and carbonated beverage.
Correct Answer: C
Rationale: Baked chicken, baked potato, and skim milk (C) are low-fat/low-cholesterol. Fried fish (A), ham/cheese/milk (B), and hamburger/fries (D) are high-fat.
The client diagnosed with subclavian steal syndrome has undergone surgery. Which assessment data would warrant immediate intervention by the nurse?
- A. The client’s pedal pulse on the left leg is absent.
- B. The client complains of numbness in the right hand.
- C. The client’s brachial pulse is strong and bounding.
- D. The client’s capillary refill time (CRT) is less than three (3) seconds.
Correct Answer: B
Rationale: Numbness in the right hand (B) post-subclavian surgery suggests nerve or vascular compromise, requiring immediate action. Absent pedal pulse (A) is unrelated, strong brachial pulse (C) is normal, and CRT <3 sec (D) is normal.
The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client's record?
- A. Peripheral vascular disease.
- B. Intermittent claudication.
- C. Deep vein thrombosis.
- D. Dependent rubor.
Correct Answer: B
Rationale: Muscle cramping/pain with walking (B) is intermittent claudication, a hallmark of arterial occlusive disease. PVD (A) is broader, DVT (C) causes swelling/pain at rest, and dependent rubor (D) is a skin color change.
The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first?
- A. Complete a neurovascular assessment.
- B. Use the Doppler device.
- C. Instruct the client to hang the feet off the side of the bed.
- D. Wrap the legs in a blanket.
Correct Answer: B
Rationale: Absent pedal pulse in PAD requires Doppler use (B) to confirm blood flow. Neurovascular assessment (A) follows, dependent position (C) worsens ischemia, and blankets (D) are irrelevant.
The nurse is preparing a client for valve replacement surgery. Which preoperative teaching is most important?
- A. You will need lifelong anticoagulant therapy.
- B. You can resume heavy lifting in 2 weeks.
- C. You will not need antibiotics before dental procedures.
- D. You should avoid all physical activity post-surgery.
Correct Answer: A
Rationale: Lifelong anticoagulation is often required post-valve replacement to prevent clot formation.