Nokea
The nurse is caring for a client who is being evaluated for arteriosclerosis obliterans. Which complaint is the client most likely to have?
- A. Burning pain in the legs that wakens him or her at night
- B. Numbness of the feet and ankles with exercise
- C. Leg pain while walking that becomes severe enough to force him or her to stop
- D. Increasing warmth and redness of the legs when they are elevated
Correct Answer: C
Rationale: Intermittent claudication, or leg pain during walking that resolves with rest, is the hallmark symptom of arteriosclerosis obliterans due to arterial insufficiency.
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During cardiopulmonary resuscitation (CPR), the nurse compresses the chest of an adult victim at which rate?
- A. No less than 15 compressions per minute
- B. No less than 40 compressions per minute
- C. No less than 80 compressions per minute
- D. No less than 100 compressions per minute
Correct Answer: D
Rationale: Adult CPR requires 100-120 compressions per minute to restore circulation effectively.
A 72-year-old man had a total hip arthroplasty eight days ago. He suddenly develops tenderness in his left calf, a slight temperature elevation, and a positive Homan's sign. Which of the following will be included in the initial care of this man?
- A. Warm packs to the left leg
- B. Vigorous massage of the left leg
- C. Placing the left leg in a dependent position
- D. Performing range of motion exercises to the left leg
Correct Answer: C
Rationale: Placing the leg in a dependent position promotes venous return and reduces swelling in suspected deep vein thrombosis. Warm packs, massage, or range of motion may dislodge a clot, increasing embolism risk.
What is the best explanation for the drug therapy in this situation?
- A. Aspirin tends to relieve chest pain.
- B. Aspirin tends to prevent blood clots.
- C. Aspirin tends to lower the blood pressure.
- D. Aspirin tendsmedi tends to dilate the coronary arteries.
Correct Answer: B
Rationale: Aspirin's antiplatelet effect prevents thrombus formation at the PTCA site, reducing the risk of re-occlusion.
The nurse provides discharge instructions for a client who has recovered after a cardiac catheterization. Which instructions should be included? Select all that apply.
- A. Take a shower rather than a tub bath until the puncture site heals.
- B. Perform leg exercises every 2 hours while awake.
- C. In the generous amount of fluids for the next 24 hours.
- D. Report worsening of pain in the leg that was catheterized.
- E. Flush the toilet twice after eliminating urine and stool in the next 24 hours.
- F. Change the dressing over the puncture site daily until it heals.
Correct Answer: A,C,D
Rationale: Showering prevents infection, generous fluids help flush contrast dye, and reporting worsening pain detects complications. Leg exercises, double flushing, and daily dressing changes are not standard.
Which assessment finding should signal the nurse to withhold applying the client's nitroglycerin patch and notify the physician?
- A. The pressure of 99.8°F (37.6°C)
- B. Respiratory rate of 24 breaths/minute at rest
- C. Apical heart rate of 90 beats/minute
- D. Blood pressure of 94/62 mm Hg
Correct Answer: D
Rationale: A blood pressure of 94/62 mm Hg indicates hypotension, a contraindication for nitroglycerin, which can further lower blood pressure.