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The nurse is caring for clients on a telemetry floor. Which nursing task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)?
- A. Teach the client how to perform a glucometer check.
- B. Assist feeding the client diagnosed with congestive heart failure.
- C. Check the cholesterol level for the client diagnosed with atherosclerosis.
- D. Assist the nurse to check the unit of blood at the client's bedside.
Correct Answer: B
Rationale: Feeding a CHF client (B) is within UAP scope and safe. Teaching glucometer (A), checking cholesterol (C), and blood verification (D) require nursing judgment.
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The client diagnosed with a deep vein thrombosis (DVT) is prescribed a heparin drip. The solution is 40,000 units in 500 mL of D5W. The health-care provider ordered the client to receive 1,200 units per hour. At which rate should the nurse set the IV pump?
Correct Answer: 15
Rationale: Heparin concentration: 40,000 units/500 mL = 80 units/mL. Dose: 1,200 units/hr ÷ 80 units/mL = 15 mL/hr. Set pump to 15 mL/hr.
The nurse is teaching the client with peripheral vascular disease. Which interventions should the nurse discuss with the client? Select all that apply.
- A. Wash your feet in antimicrobial soap.
- B. Wear comfortable, well-fitting shoes.
- C. Cut your toenails in an arch.
- D. Keep the area between the toes dry.
- E. Use a heating pad when feet are cold.
Correct Answer: B,D
Rationale: Well-fitting shoes (B) prevent injury, and dry toes (D) prevent infection in PVD. Antimicrobial soap (A) is unnecessary, arched toenails (C) risk ingrown nails, and heating pads (E) risk burns.
Which nursing instruction is most beneficial in helping relieve the client's symptoms caused by varicose veins?
- A. Elevate your legs frequently during the day.
- B. Keep the room temperature above 70°F (21°C).
- C. Massage your calves when experiencing leg cramps.
- D. Modify your lifestyle to include sedentary activities.
Correct Answer: A
Rationale: Elevating the legs promotes venous return, reducing swelling and discomfort associated with varicose veins.
Which dietary recommendation should the nurse provide to a client with hypertension?
- A. Follow the DASH diet.
- B. Increase red meat consumption.
- C. Drink caffeinated beverages daily.
- D. Use table salt liberally.
Correct Answer: A
Rationale: The DASH diet, rich in fruits, vegetables, and low-fat dairy, is proven to lower blood pressure.
The nurse is assessing the client diagnosed with long-term arterial occlusive disease. Which assessment data support the diagnosis?
- A. Hairless skin on the legs.
- B. Brittle, flaky toenails.
- C. Petechiae on the soles of feet.
- D. Nonpitting ankle edema.
Correct Answer: A
Rationale: Hairless skin (A) indicates chronic ischemia in PAD. Brittle nails (B) are nonspecific, petechiae (C) suggest bleeding, and nonpitting edema (D) is unrelated (pitting edema is venous).