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The nurse is caring for a client scheduled for a surgical repair of an abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
- A. Assessment of the client's level of anxiety
- B. Evaluation of the client's exercise tolerance
- C. Identification of peripheral pulses
- D. Assessment of bowel sounds and activity
Correct Answer: C
Rationale: Identifying peripheral pulses is critical to establish a baseline for vascular status, as an abdominal aortic aneurysm repair can affect blood flow to the extremities, and postoperative complications may include vascular occlusion.
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The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?
- A. It will be alright for your friends to autograph the cast.
- B. Because the cast is made of plaster, autographing can weaken the cast.
- C. If they don't use chalk to autograph, it is okay.
- D. Autographing or writing on the cast in any form will harm the cast.
Correct Answer: A
Rationale: Autographing a fiberglass cast does not compromise its integrity, making it safe.
The nurse has performed discharge teaching to a client in need of a high-iron diet. The nurse recognizes that teaching has been effective when the client selects which meal plan?
- A. Hamburger, French fries, and orange juice
- B. Sliced veal, spinach salad, and whole-wheat roll
- C. Vegetable lasagna, Caesar salad, and toast
- D. Bacon, lettuce, and tomato sandwich; potato chips; and tea
Correct Answer: B
Rationale: Veal and spinach are high in iron, and whole-wheat roll provides additional nutrients. The other meals lack significant iron sources.
Prior to drawing blood for blood gas analysis, the nurse conducts the modified Allen test to ensure there is adequate collateral circulation. The nurse asks the client to extend the wrist over a rolled towel and make a fist. Place the following steps (Roman numerals) in order from first to last.
- A. Ask the client to open and close the hand until the skin blanches.
- B. Palpate the ulnar and radial pulses and apply pressure to both arteries.
- C. Observe the hand for color.
- D. Release the ulnar artery while maintaining pressure on the radial artery.
Correct Answer: A,B,D,C
Rationale: Modified Allen test sequence: Blanch hand (I), compress arteries (II), release ulnar artery (IV), observe color return (III) to confirm collateral circulation.
A nurse prepares to administer a transfusion of RBCs and takes the client's vital signs. The client's temperature is 102.7°F, but other vitals are within normal limits. The nurse should
- A. transfuse the RBC as ordered.
- B. administer an antipyretic and transfuse the RBCs.
- C. transfuse the RBCs but monitor the temperature hourly.
- D. not transfuse the RBCs and instead contact the physician.
Correct Answer: D
Rationale: Fever (102.7°F) may indicate an infection or transfusion reaction risk. The physician should be contacted before proceeding with the transfusion.
The nurse should visit which of the following clients first?
- A. The client with diabetes with a blood glucose of 95 mg/dL
- B. The client with hypertension being maintained on Lisinopril
- C. The client with chest pain and a history of angina
- D. The client with Raynaud's disease
Correct Answer: C
Rationale: Chest pain in a client with a history of angina suggests possible cardiac ischemia, requiring immediate assessment.