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The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD). During the assessment, the nurse should expect to find which of the following clinical manifestations of PVD?
- A. Hairy legs
- B. Mottled skin
- C. Pink, cool skin
- D. Warm, moist skin
Correct Answer: B
Rationale: Mottled skin (livedo reticularis) is a common manifestation of PVD due to poor perfusion, causing irregular skin discoloration. Hairy legs, pink cool skin, or warm moist skin are not typical; PVD often presents with hair loss, cool, pale, or cyanotic skin.
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Multiple clients have been brought to the emergency department after being struck by lightning during a severe thunderstorm. Which of the following clients should the nurse prioritize? The client who?
- A. reports numbness and tingling in all their extremities.
- B. has paralysis on both lower extremities.
- C. is confused and cannot remember their name or why they are in the emergency department.
- D. experienced a massive electrical current discharge to their body.
Correct Answer: B
Rationale: Paralysis in both lower extremities indicates potential spinal cord injury or severe neurological damage, requiring immediate prioritization. Numbness and tingling (A) suggest peripheral nerve issues, confusion (C) may indicate concussion or hypoxia, and massive discharge (D) lacks specific clinical urgency without symptoms.
Health maintenance and promotion activities are especially important for the older adult. Which of the following activities reflects the ability of chance activity for an otherwise healthy older adult?
- A. Drinks 1,500 mL of fluids per day.
- B. Consumes a balanced diet of 1,200 calories per day.
- C. Walks briskly for 10 minutes three times per week.
- D. Sleeps at least 8 hours each night.
Correct Answer: C
Rationale: Brisk walking promotes cardiovascular health and mobility. 1,500 mL fluid may be insufficient, 1,200 calories is too low for most, and 8 hours sleep is not activity-focused.
What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.
A client who had an esophageal hernia repair 4 hours ago has a pulse rate of 90 bpm, respiration rate of 16/minute, blood pressure of 130/80 mm Hg, pulse oximeter of 91, and a temperature of 100.4°F (38°C). What should the nurse do first?
- A. Obtain a culture of the incision.
- B. Notify the surgeon to obtain an antibiotic order.
- C. Adjust the client to a sitting position to take deep breaths.
- D. Administer an antipyretic medication.
Correct Answer: C
Rationale: A pulse oximetry of 91 indicates mild hypoxemia. Adjusting to a sitting position and encouraging deep breaths improves oxygenation, addressing the most immediate concern.
The nurse has reported to the hospital to work the evening shift on a respiratory unit. The nurse's assignment consists of four clients. Prioritize in order from highest to lowest priority how the nurse would assess the clients after receiving report.
- A. An 85-year-old client with bacterial pneumonia, temperature of 102.2°F (42°C), and shortness of breath.
- B. A 60-year-old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting something for pain.
- C. A 35-year-old client with suspected tuberculosis who is complaining of a cough.
- D. A 56-year-old client with emphysema who has a scheduled dose of a bronchodilator due to be administered, with no report of acute respiratory distress.
Correct Answer: A,B,C,D
Rationale: The client with pneumonia, fever, and shortness of breath is at highest risk for respiratory compromise (A). The postoperative client with pain (B) is next due to pain's impact on breathing. The client with suspected tuberculosis and cough (C) is lower priority but needs isolation precautions. The client with emphysema awaiting a scheduled bronchodilator (D) is stable.