Nokea
The nurse is caring for a client who is receiving heparin therapy intravenously. Which assessment data would indicate to the nurse the client is developing heparin-induced thrombocytopenia (HIT)? Select all that apply.
- A. The client has spontaneous bleeding from around the IV site.
- B. The client complains of chest pain on inspiration and has become restless.
- C. The client’s platelet count on admission was 420 (103) and now is 200 (103).
- D. The client complains that the gums bleed when brushing the teeth.
- E. The client has developed skin lesions at the IV site.
Correct Answer: A,C,D
Rationale: HIT causes thrombocytopenia and bleeding: IV site bleeding (A), platelet drop from 420 to 200 (C), and gum bleeding (D) are signs. Chest pain/restlessness (B) suggests PE, and skin lesions (E) are not typical.
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Which question should the nurse ask the male client diagnosed with aortoiliac disease during the admission interview?
- A. Do you have trouble sitting for long periods of time?'
- B. How often do you have a bowel movement and urinate?'
- C. When you lie down, do you feel throbbing in your abdomen?'
- D. Have you experienced any problems having sexual intercourse?'
Correct Answer: D
Rationale: Aortoiliac disease can cause erectile dysfunction due to reduced pelvic blood flow, making sexual intercourse issues (D) relevant. Sitting (A), bowel/urination (B), and throbbing (C) are less specific.
The nurse is discussing the pathophysiology of atherosclerosis with a client who has a normal high-density lipoprotein (HDL) level. Which information should the nurse discuss with the client concerning HDLs?
- A. A normal HDL is good because it has a protective action in the body.
- B. The HDL level measures the free fatty acids and glycerol in the blood.
- C. HDLs are the primary transporters of cholesterol into the cell.
- D. The client needs to decrease the amount of cholesterol and fat in the diet.
Correct Answer: A
Rationale: Normal HDL (A) is protective, removing cholesterol from arteries. HDL doesn’t measure fatty acids (B) or transport cholesterol into cells (C), and diet (D) is unrelated to normal HDL.
The nurse is monitoring a client with atrial fibrillation. Which finding is most concerning?
- A. Heart rate of 110 beats per minute
- B. Blood pressure of 140/90 mmHg
- C. Dizziness and shortness of breath
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Dizziness and shortness of breath suggest hemodynamic instability, which is concerning in atrial fibrillation.
When assessing the client's lower leg, which findings characteristic of venous stasis ulcers is the nurse most likely to find? Select all that apply.
- A. Purulent drainage from lesions
- B. Blanched patches around open areas
- C. Dark brown, dry, and crusty skin
- D. Fluid-filled blisters
- E. Edema in the lower legs
- F. Fine red rash below the knee
Correct Answer: C,E
Rationale: Venous stasis ulcers are typically characterized by dark brown, dry, crusty skin due to hemosiderin deposition and edema in the lower legs due to venous insufficiency.
Which instruction should the nurse discuss with the client diagnosed with Raynaud's phenomenon?
- A. Explain exacerbations will not occur in the summer.
- B. Use nicotine gum to help quit smoking.
- C. Wear extra-warm clothing during cold exposure.
- D. Avoid prolonged exposure to direct sunlight.
Correct Answer: C
Rationale: Cold triggers Raynaud’s; wearing warm clothing (C) prevents vasospasm. Exacerbations occur in summer (A), nicotine gum (B) still delivers nicotine (harmful), and sunlight (D) is irrelevant.