Nokea
The nurse is caring for clients on a medical floor. Which client will the nurse assess first?
- A. The client with an abdominal aortic aneurysm who is constipated.
- B. The client on bedrest who ambulated to the bathroom.
- C. The client with essential hypertension who has epistaxis and a headache.
- D. The client with arterial occlusive disease who has a decreased pedal pulse.
Correct Answer: D
Rationale: Decreased pedal pulse in arterial occlusive disease (D) suggests acute ischemia, a priority. Constipation (A), unauthorized ambulation (B), and epistaxis/headache (C) are less urgent.
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Which actions should the surgical scrub nurse take to prevent personally developing a DVT?
- A. Keep the legs in a dependent position and stand as still as possible.
- B. Flex the leg muscles and change the leg positions frequently.
- C. Wear white socks and shoes that have an elevated heel.
- D. Ask the surgeon to allow the nurse to take a break midway through each surgery.
Correct Answer: B
Rationale: Flexing muscles and changing positions (B) promote venous return, preventing DVT. Dependent position (A) increases risk, socks/heels (C) are irrelevant, and breaks (D) are impractical.
The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins?
- A. Wear low-heeled, comfortable shoes.
- B. Wear clean white cotton socks.
- C. Move the legs back and forth often.
- D. Wear graduated compression hose.
Correct Answer: D
Rationale: Compression hose (D) prevent venous pooling, reducing varicose vein risk. Low heels (A), socks (B), and leg movement (C) help but are less effective.
The client diagnosed with atherosclerosis asks the nurse, 'I have heard of atherosclerosis for many years but I never really knew what it meant. Am I going to die?' Which statement would be the nurse’s best response?
- A. This disease process will not kill you, so don’t worry.'
- B. The blood supply to your brain is being cut off.'
- C. It is what caused you to have your high blood pressure.'
- D. Atherosclerosis is a buildup of plaque in your arteries.'
Correct Answer: D
Rationale: Atherosclerosis is plaque buildup in arteries (D), a clear and accurate response. It’s not always fatal (A), doesn’t primarily affect brain (B), and isn’t the sole cause of hypertension (C).
Which finding in a client with cardiomyopathy indicates a need for immediate action?
- A. Blood pressure of 130/85 mmHg
- B. New irregular heart rhythm
- C. Mild leg swelling
- D. Fatigue after activity
Correct Answer: B
Rationale: A new irregular heart rhythm may indicate a life-threatening arrhythmia, requiring immediate intervention.
The wife of a client with arterial occlusive disease tells the nurse, 'My husband says he is having rest pain. What does that mean?' Which statement by the nurse would be most appropriate?
- A. It describes the type of pain he has when he stops walking.'
- B. His legs are deprived of oxygen during periods of inactivity.'
- C. You are concerned that your husband is having rest pain.'
- D. This term is used to support that his condition is getting better.'
Correct Answer: B
Rationale: Rest pain (B) occurs in severe PAD due to inadequate oxygen supply at rest. Pain when stopping (A) is claudication, concern (C) avoids the question, and improvement (D) is incorrect (rest pain indicates worsening).