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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Digoxin (Lanoxin) and furosemide (Lasix) are ordered for a client who has congestive heart failure. Which of the following would the nurse also expect to be ordered for this client?
- A. Potassium
- B. Calcium
- C. Aspirin
- D. Coumadin
Correct Answer: A
Rationale: Furosemide, a diuretic, can cause potassium loss, leading to hypokalemia, which increases the risk of digoxin toxicity. Potassium supplements are often ordered to maintain normal levels.
When obtaining a health history from the client, the nurse would expect to learn that which of the following was the client's earliest symptom?
- A. Anorexia
- B. Dyspnea
- C. Nausea
- D. Headaches
Correct Answer: B
Rationale: Dyspnea is often the earliest symptom of left-sided heart failure due to pulmonary congestion.
If the client develops digoxin toxicity, what would the nurse expect the client to exhibit?
- A. Anorexia and nausea
- B. Dizziness and insomnia
- C. Pinpoint pupils and double vision
- D. Ringing in the ears and itchy skin
Correct Answer: A
Rationale: Digoxin toxicity commonly causes anorexia, nausea, and vomiting due to gastrointestinal effects.
When the nurse is obtaining this client's health history, which question about pain is least helpful?
- A. How long have you been in pain?
- B. Where is your pain located?
- C. What were you doing when your pain started?
- D. What medications do you take for pain?
Correct Answer: D
Rationale: Asking about pain medications is less critical in the acute MI setting compared to timing, location, and triggers, which guide diagnosis and urgency.
Which response by the nurse is most accurate?
- A. Sustained hypertension decreases thenvim life span of many blood cells.
- B. Sustained hypertension leads to the formation of venous blood clots.
- C. Sustained hypertension compromises blood flow to many vital organs.
- D. Sustained hypertension predisposes to narrowing of the cardiac valves.
Correct Answer: C
Rationale: Sustained hypertension increases vascular resistance, which can compromise blood flow to vital organs like the heart, brain, and kidneys, leading to organ damage.