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The nurse is caring for clients on a surgical floor. Which client should be assessed first?
- A. The client who is four (4) days postoperative abdominal surgery and is complaining of left calf pain when ambulating.
- B. The client who is one (1) day postoperative hernia repair who has just been able to void 550 mL of clear amber urine.
- C. The client who is five (5) days postoperative open cholecystectomy who has a T-tube and is being discharged.
- D. The client who is 16 hours post-abdominal hysterectomy and is complaining of abdominal pain and is expelling flatus.
Correct Answer: A
Rationale: Calf pain post-surgery (A) suggests DVT, requiring immediate assessment. Normal voiding (B), discharge (C), and expected pain/flatus (D) are less urgent.
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The client with a pacemaker asks how to check if it is working. What is the best response?
- A. Check your pulse regularly.
- B. Monitor your blood pressure daily.
- C. Weigh yourself every morning.
- D. Measure your temperature daily.
Correct Answer: A
Rationale: Checking the pulse ensures the pacemaker is maintaining an appropriate heart rate.
Which assessment data would support that the client has a venous stasis ulcer?
- A. A superficial pink open area on the medial part of the ankle.
- B. A deep pale open area over the top side of the foot.
- C. A reddened blistered area on the heel of the foot.
- D. A necrotic gangrenous area on the dorsal side of the foot.
Correct Answer: A
Rationale: Venous stasis ulcers are superficial, pink, and medial (A) due to venous pooling. Deep/pale (B) or necrotic (D) ulcers suggest arterial insufficiency, and blisters (C) are unrelated.
The nurse is teaching a class on coronary artery disease. Which modifiable risk factor should the nurse discuss when teaching about atherosclerosis?
- A. Stress.
- B. Age.
- C. Gender.
- D. Family history.
Correct Answer: A
Rationale: Stress (A) is a modifiable risk factor for atherosclerosis (e.g., via lifestyle changes). Age (B), gender (C), and family history (D) are non-modifiable.
Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency?
- A. Decreased pedal pulses.
- B. Cool skin temperature.
- C. Intermittent claudication.
- D. Brown discolored skin.
Correct Answer: D
Rationale: Brown discoloration (D) results from hemosiderin deposits in venous insufficiency. Decreased pulses (A) and claudication (C) are arterial, and cool skin (B) is not typical (skin is often warm).
The client diagnosed with subclavian steal syndrome has undergone surgery. Which assessment data would warrant immediate intervention by the nurse?
- A. The client’s pedal pulse on the left leg is absent.
- B. The client complains of numbness in the right hand.
- C. The client’s brachial pulse is strong and bounding.
- D. The client’s capillary refill time (CRT) is less than three (3) seconds.
Correct Answer: B
Rationale: Numbness in the right hand (B) post-subclavian surgery suggests nerve or vascular compromise, requiring immediate action. Absent pedal pulse (A) is unrelated, strong brachial pulse (C) is normal, and CRT <3 sec (D) is normal.