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The nurse is caring for a client who is two days postoperative following a right femoral popliteal bypass surgery. The client reports worsening pain, and the assessment showed swelling and ecchymosis at the incision sites. The nurse should initially
- A. Apply pressure to sites with sandbag
- B. Palpate pedal pulses
- C. Assess for signs of claudication
- D. Apply warm compress to incision sites
Correct Answer: B
Rationale: Worsening pain, swelling, and ecchymosis at the incision sites suggest possible complications such as hematoma or compromised vascular flow. Palpating pedal pulses is the priority to assess the patency of the bypass graft and ensure adequate distal perfusion. Applying pressure or warm compresses could exacerbate bleeding or swelling, and claudication assessment is less urgent than confirming vascular integrity.
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The nurse is teaching at an interdisciplinary conference focused on age-related changes. Which of the following are expected in the older adult? Select all that apply.
- A. Fatty tissue is redistributed
- B. Skin becomes less elastic
- C. Cardiac output increases
- D. Muscle mass increases
- E. Hormone production increases
- F. Visual and hearing acuity diminishes
Correct Answer: A,B,F
Rationale: Aging involves fat redistribution, less elastic skin, and diminished sensory acuity. Cardiac output, muscle mass, and hormone production decrease.
The nurse is performing a health assessment on a client. While performing percussion, which percussion sound would require follow-up?
- A. Dull tone over the spleen
- B. Hyperresonance over an adult's lung tissue
- C. Flat tone over bone
- D. Hyperresonance over a child's lung tissue
Correct Answer: B
Rationale: Hyperresonance in adult lungs suggests pneumothorax or emphysema, requiring follow-up. Dullness over spleen, flatness over bone, and hyperresonance in children are normal.
The nurse in the emergency department (ED) is caring for a child with erythema infectiosum (Fifth disease). Which transmission-based precautions should the nurse implement?
- A. Standard
- B. Droplet
- C. Contact
- D. Airborne
Correct Answer: A
Rationale: Erythema infectiosum is typically non-infectious once the rash appears, requiring only standard precautions.
The nurse is teaching a client how to ambulate using a walker. The nurse should
- A. Have the client stand on the side of the walker to have them properly fitted.
- B. Position the top of the walker so it lines up with the client's wrist crease.
- C. Ensure the client's feet are close together while holding onto the walker handgrips.
- D. Instruct the client to lean forward over the walker so they do not lose balance.
- G. None
Correct Answer: B
Rationale: The walker’s top aligns with the wrist crease for proper height. Standing on the side, close feet, or leaning forward are unsafe or incorrect for fitting or use.
The nurse is caring for a client who has a prescribed regular insulin sliding scale. At 0800, the client's capillary blood glucose (CBG) was 258 mg/dl (14.29 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. At 1215 the CBG was 288 mg/dl (15.984 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. At 1730 the CBG was 254 mg/dI (14.097 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. The nurse should do which of the following at 1730?
- A. Administer 8 units of regular insulin
- B. Administer 6 units of regular insulin
- C. Notify the primary health care provider (PHCP)
- D. Withhold the prescribed insulin
- E. Modify the client's prescribed diet to low sodium
Correct Answer: B,C
Rationale: Per the sliding scale, 254 mg/dL requires 6 units of insulin, and three consecutive CBGs >250 mg/dL require notifying the PHCP.