Nokea
The nurse is caring for the client with chronic venous insufficiency. Which statement indicates the client understands the discharge teaching?
- A. I shouldn’t cross my legs for more than 15 minutes.'
- B. I need to elevate the foot of my bed while sleeping.'
- C. I should take a baby aspirin every day with food.'
- D. I should increase my fluid intake to 3,000 mL a day.'
Correct Answer: B
Rationale: Elevating the bed (B) reduces edema in venous insufficiency. Crossing legs (A) is discouraged entirely, aspirin (C) is for arterial issues, and 3,000 mL (D) risks fluid overload.
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The nurse is preparing a client for valve replacement surgery. Which preoperative teaching is most important?
- A. You will need lifelong anticoagulant therapy.
- B. You can resume heavy lifting in 2 weeks.
- C. You will not need antibiotics before dental procedures.
- D. You should avoid all physical activity post-surgery.
Correct Answer: A
Rationale: Lifelong anticoagulation is often required post-valve replacement to prevent clot formation.
The client presents to the outpatient clinic complaining of calf pain. The client reports returning from an airplane trip the previous day. Which should the nurse assess first?
- A. The nurse should auscultate the lung fields and heart sounds.
- B. The nurse should determine the length of the airplane trip.
- C. The nurse should determine if the client has had chest pain.
- D. The nurse should measure the calf and palpate the calf for warmth.
Correct Answer: C
Rationale: Calf pain post-flight suggests DVT; assessing for chest pain (C) rules out pulmonary embolism, a priority. Lung/heart sounds (A), trip length (B), and calf exam (D) follow.
The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?
- A. I have stomach pain every time I eat a big, heavy meal.'
- B. I don’t have any abdominal pain or any type of problems.'
- C. I have periodic episodes of constipation and then diarrhea.'
- D. I belch a lot, especially when I lie down after eating.'
Correct Answer: B
Rationale: Small AAAs are often asymptomatic (B). Postprandial pain (A), bowel changes (C), and belching (D) suggest GI issues, not AAA.
Which diagnostic test should the nurse expect for a client with suspected endocarditis?
- A. Blood cultures
- B. Chest X-ray
- C. Urinalysis
- D. Liver function tests
Correct Answer: A
Rationale: Blood cultures identify the causative organism in endocarditis.
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.