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The nurse is assessing a client on admission to the hospital. The client's leg appears with dependent rubor. What action by the nurse is best?
- A. Assess the client's ankle-brachial index
- B. Elevate the leg above the heart
- C. Obtain an ice pack to provide comfort
- D. Administer heparin sodium
Correct Answer: A
Rationale: Dependent rubor is a classic finding in peripheral arterial disease. The nurse should measure the ankle-brachial index to assess the severity. Elevating the leg or using ice could worsen circulation, and heparin is not indicated for this condition.
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A nurse wants to provide community service that helps meet the goals of Healthy People 2020 related to cardiovascular disease and stroke. What activity would best meet this goal?
- A. Teach a class on heart-healthy diets
- B. Participate in blood pressure screenings at the mall
- C. Provide pamphlets on heart disease at the grocery store
- D. Set up an information booth at the pet store
Correct Answer: B
Rationale: An important goal of Healthy People 2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether it was normal or high. Blood pressure screenings in a public place best meet this goal.
An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice nurse. What statement by the client may indicate a barrier to proper foot care?
- A. I nearly always wear comfy sweatpants and house shoes
- B. I'm glad I get energy assistance so my house isn't so cold
- C. I check my feet every day for cuts or sores
- D. My hands shake when I try to do things requiring coordination
Correct Answer: D
Rationale: Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails, indicating a barrier to proper foot care. The nurse should refer this client to a podiatrist.
A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information?
- A. Could you walk further than that a few months ago?
- B. Do you walk mostly uphill, downhill, or on flat surfaces?
- C. Have you ever considered swimming instead of walking?
- D. How much pain medication do you take each day?
Correct Answer: A
Rationale: As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain-free indicates the client's disease is worsening. The other questions are useful but not as critical.
A nurse is caring for a client who weighs 207 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your answer using a whole number.) __ mg
- A. 90
- B. 80
- C. 100
- D. 70
Correct Answer: A
Rationale: The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 207 pounds (94 kg), so the nurse anticipates administering the maximum dose of 90 mg.
The nurse is caring for four hypertensive clients. Which drug/laboratory value combination should the nurse report immediately to the health care provider?
- A. Furosemide (Lasix)/potassium 2.1 mEq/L
- B. Hydrochlorothiazide/potassium 3.5 mEq/L
- C. Spironolactone (Aldactone)/potassium 5.1 mEq/L
- D. Losartan/sodium 135 mEq/L
Correct Answer: A
Rationale: Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is critically low and should be reported immediately. A potassium level of 5.1 mEq/L is on the high side but not as critical. The other laboratory values are within normal ranges.