Nokea
The nurse is caring for a client with chronic venous insufficiency. Which of the following findings would be consistent with the condition?
- A. absent pedal pulses bilaterally
- B. toes cold to palpation bilaterally
- C. absence of hair on the lower extremities
- D. brown, hardened skin on the lower extremities
Correct Answer: D
Rationale: Brown, hardened skin (lipodermatosclerosis) is characteristic of chronic venous insufficiency due to hemosiderin deposition and fibrosis.
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A client with an implantable cardioverter defibrillator (ICD) develops ventricular tachycardia (VT) with a pulse while admitted to the medical-surgical unit. The ICD fires multiple times without successfully stopping the VT, causing the client to become confused and difficult to rouse. Which action by the nurse is appropriate?
- A. Attempt to stimulate a vagal response by having the client cough
- B. Deactivate the client's implantable cardioverter defibrillator with an external magnet
- C. Obtain a STAT 12-lead ECG to verify the cardiac rhythm
- D. Prepare for synchronized cardioversion with the external defibrillator
Correct Answer: D
Rationale: Persistent VT causing altered mental status requires synchronized cardioversion to restore normal rhythm.
A woman who is 32 weeks gestation comes to her physician's office. Which finding is of most concern to the office nurse?
- A. Trace of glucose in the urine
- B. Weight gain of 4 lb in one month
- C. Swelling around the client's eyes
- D. Ankle and foot edema
Correct Answer: C
Rationale: Periorbital swelling at 32 weeks suggests preeclampsia, a serious condition requiring immediate evaluation. Trace glucose, 4-lb weight gain, or ankle edema are less concerning.
Triazolam (Halcion) 0.25 mg is ordered for a client at bedtime. When the nurse goes to give the medication, the client asks the nurse to leave it at the bedside because she wants to finish reading a book. What is the best action for the nurse to take?
- A. Leave the medication at the bedside as requested
- B. Return in one hour and offer the medication again
- C. Tell the client to call when she is ready for the medication
- D. Explain to the client that this is the time medications are given and she should take it now
Correct Answer: B
Rationale: Returning in an hour ensures medication administration while respecting the client's request, adhering to safety protocols. Leaving medication or delaying indefinitely risks errors.
The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?
- A. 1 mL
- B. 3 mL
- C. 10 mL
- D. 30 mL
Correct Answer: C
Rationale: A 10 mL syringe is recommended to avoid excessive pressure that could damage the catheter.
In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in
- A. Hearing, speech, and sight
- B. Endurance, strength, and mobility
- C. Learning, creativity, and judgment
- D. Balance, flexibility, and coordination
Correct Answer: C
Rationale: Learning, creativity, and judgment. Cognitive impairments are due to physiological processes that affect memory and other higher-level cognitive processes.