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The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. Which assessment provides the most accurate information about the client's postoperative status?
- A. Radial pulse
- B. Pedal pulse
- C. Brachial pulse
- D. Popliteal pulse
Correct Answer: B
Rationale: Assessing the pedal pulse post-femoral-popliteal bypass is most accurate for evaluating graft patency and distal perfusion. A palpable or Doppler-detected pedal pulse indicates successful restoration of blood flow to the lower extremity. Other pulses (radial, brachial, popliteal) are less specific to the surgical site.
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A 28-year-old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse's best response is which of the following?
- A. Febrile reactions are caused when antibodies on the surface of blood cells in the transfusion are directed against antigens of the recipient.
- B. Febrile reactions can usually be prevented by administering antipyretics and antihistamines before the start of the transfusion.
- C. Febrile reactions are rarely immune-mediated and can be a sign of hemolytic transfusion.
- D. Febrile reactions primarily occur within 15 minutes after initiation of the transfusion and can occur during the blood transfusion.
Correct Answer: B
Rationale: Febrile reactions can often be prevented with premedication like antipyretics and antihistamines, which is a reassuring and accurate response for the client.
A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications?
- A. Deficient fluid volume.
- B. Intestinal obstruction.
- C. Bowel ischemia.
- D. Peritonitis.
Correct Answer: D
Rationale: Fever, tachycardia, and hypotension in acute appendicitis suggest peritonitis, a complication from possible appendiceal rupture. Deficient fluid volume, obstruction, or ischemia are less directly indicated by these signs. CN: Physiological adaptation; CL: Analyze
Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease?
- A. Encouraging regular ambulation.
- B. Promoting bowel rest.
- C. Maintaining current weight.
- D. Decreasing episodes of rectal bleeding.
Correct Answer: B
Rationale: Promoting bowel rest is the priority during a Crohn's exacerbation to reduce inflammation and symptoms. Ambulation, weight maintenance, and reducing bleeding are secondary to resting the bowel. CN: Physiological adaptation; CL: Synthesize
The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit?
- A. I can use heat and cold as often as I want.'
- B. With heat, I should apply it for no longer than 20 minutes at a time.'
- C. Heat-producing liniments can be used with other heat devices.'
- D. Ten to 15 minutes per application is the maximum time for cold applications.'
Correct Answer: A
Rationale: Frequent or prolonged use of heat and cold without guidance can cause tissue damage. The other statements reflect appropriate understanding of time limits and safe use.
The client asks the nurse what his activity limitations are while he is in Buck's traction. The nurse should tell the client:
- A. You can sit up whenever you want.'
- B. You must lie flat on your back most of the time.'
- C. You can turn your body.'
- D. You must lie on your stomach.'
Correct Answer: B
Rationale: Buck's traction requires lying flat to maintain traction alignment, limiting movement.