Nokea
The nurse is observing a client who is learning to perform Buerger-Allen exercises. The nurse knows that the client is performing these exercises correctly when the client is observed doing what?
- A. Alternately dorsiflexing and plantar flexing the feet while the legs are elevated
- B. Massaging the legs beginning at the feet and moving toward the heart
- C. Alternately walking short distances and resting with the legs elevated
- D. Elevating the legs, then dangling them, and then lying flat for three minutes in each position
Correct Answer: D
Rationale: Buerger-Allen exercises involve elevating the legs to promote arterial emptying, dangling to promote filling, and lying flat to rest, performed in cycles to improve circulation.
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The nurse checking the client's leg incision is aware that which is the most common blood vessel used in CABG surgery?
- A. The saphenous vein
- B. The femoral artery
- C. The popliteal vein
- D. The iliac artery
Correct Answer: A
Rationale: The saphenous vein is commonly used in CABG due to its accessibility and suitability for grafting.
A 72-year-old man had a total hip arthroplasty eight days ago. He suddenly develops tenderness in his left calf, a slight temperature elevation, and a positive Homan's sign. Which of the following will be included in the initial care of this man?
- A. Warm packs to the left leg
- B. Vigorous massage of the left leg
- C. Placing the left leg in a dependent position
- D. Performing range of motion exercises to the left leg
Correct Answer: C
Rationale: Placing the leg in a dependent position promotes venous return and reduces swelling in suspected deep vein thrombosis. Warm packs, massage, or range of motion may dislodge a clot, increasing embolism risk.
If the literature supplied by the fast-food chain indicates that one hot apple pie contains 2 g of protein, 14 g of fat, and 31 g of carbohydrates, how many calories are contained in one hot apple pie?
- A. 250 calories
- B. 260 calories
- C. 270 calories
- D. 280 calories
Correct Answer: C
Rationale: Calories are calculated as: (2 g protein × 4 kcal/g) + (14 g fat × 9 kcal/g) + (31 g carbohydrates × 4 kcal/g) = 8 + 126 + 124 = 258 kcal, closest to 270 kcal.
The nurse is preparing a client for a cardiac catheterization. Which action would the nurse expect to take?
- A. Administer a radioisotope as ordered.
- B. Give the client a cleansing enema.
- C. Locate and mark peripheral pulses.
- D. Encourage high fluid intake before the test.
Correct Answer: C
Rationale: Locating and marking peripheral pulses before cardiac catheterization allows for post-procedure comparison to detect complications like arterial occlusion. Radioisotopes, enemas, and high fluid intake are not standard preparations for this procedure.
A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?
- A. Gallbladder disease
- B. Liver disease
- C. Myocardial infarction
- D. Skeletal muscle injury
Correct Answer: C
Rationale: AST is an enzyme released in response to tissue damage. The symptoms of chest pain and shortness of breath, along with elevated AST 24 hours later, are suggestive of myocardial infarction. AST rises after a myocardial infarction but may also rise with liver damage or skeletal muscle injury. Gallbladder disease typically presents with pain in the right scapula region and would not have an elevated AST.