Nokea
The nurse is admitting a client diagnosed with peripheral vascular disease. Which data support a diagnosis of venous insufficiency?
- A. The client has bright red skin on the lower extremities.
- B. The client has a brownish purple area on the lower legs.
- C. The client complains of pain after ambulating for short distances.
- D. The client has nonhealing wounds on the toes and ankles.
Correct Answer: B
Rationale: Brownish purple skin (B) indicates hemosiderin from venous stasis. Red skin (A) is nonspecific, pain with walking (C) is arterial, and toe/ankle wounds (D) are arterial.
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The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse?
- A. The telemetry reads normal sinus rhythm.
- B. The client has a weight gain of 2 kg within 1 to 2 days.
- C. The client's blood pressure is 148/92.
- D. The client's serum potassium level is 4.5 mEq.
Correct Answer: B
Rationale: Weight gain of 2 kg in 1–2 days (B) indicates fluid retention, a serious issue in hypertension requiring intervention. Normal sinus rhythm (A), BP 148/92 (C), and K+ 4.5 (D) are not urgent.
The client with endocarditis is at risk for which complication?
- A. Embolism
- B. Hypoglycemia
- C. Osteoarthritis
- D. Pancreatitis
Correct Answer: A
Rationale: Endocarditis can cause vegetations on heart valves, which may break off and form emboli.
The client with atrial fibrillation is prescribed warfarin. Which laboratory value should the nurse monitor?
- A. Platelet count
- B. International normalized ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Red blood cell count
Correct Answer: B
Rationale: Warfarin's anticoagulant effect is monitored using INR to ensure therapeutic levels and prevent bleeding or clotting.
The nurse is administering heparin to a client with a DVT. Which laboratory value should the nurse monitor closely?
- A. International normalized ratio (INR)
- B. Activated partial thromboplastin time (aPTT)
- C. Platelet count
- D. Red blood cell count
Correct Answer: B
Rationale: Heparin's anticoagulant effect is monitored using aPTT to ensure therapeutic dosing and prevent bleeding.
Which client would be most likely to develop an abdominal aortic aneurysm?
- A. A 45-year-old female with a history of osteoporosis.
- B. An 80-year-old female with congestive heart failure.
- C. A 69-year-old male with peripheral vascular disease.
- D. A 30-year-old male with a genetic predisposition to AAA.
Correct Answer: C
Rationale: Older males with PVD (C) are at highest risk for AAA due to atherosclerosis. Osteoporosis (A), CHF (B), and young age (D) are lower risk, even with genetics.