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The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?
- A. Uneven hair distribution.
- B. Lower leg edema.
- C. Bronze pigmentation.
- D. Bounding peripheral pulse.
Correct Answer: A
Rationale: Uneven hair distribution results from reduced blood flow impairing hair follicle nutrition, a sign of peripheral arterial disease.
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A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?
- A. Impaired renal function related to pain.
- B. Acute pain related to renal calculus.
- C. Risk for aspiration related to vomiting.
- D. Nutritional deficit related to nausea.
Correct Answer: C
Rationale: Risk for aspiration is the highest priority due to the immediate threat of airway obstruction from vomiting.
The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
- A. Notify the healthcare provider of the client's medication history.
- B. Have the client sign the surgical and transfusion permits.
- C. Observe the heparin injections sites for signs of bruising.
- D. Ensure that the potential for bleeding is explained to the client.
Correct Answer: A
Rationale: Notifying the provider about heparin use is critical to manage perioperative bleeding risk due to its anticoagulant effects.
Nurses' Notes
Physical Examination
Vital Signs
Day 1, 0830
Body mass index (BMI) is 31.8 kg/m2
Pain rating of 8 on 0 to 10 scale, in the right foot
Client history has been collected, and the nurse performs a physical assessment and records vital signs
Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.
- A. Drinks beer nightly
- B. Hypertension
- C. Sleep apnea
- D. Ibuprofen for pain
- E. Daily aspirin
- F. Type 2 diabetes mellitus
- G. osteoarthritis
Correct Answer: A,B,F,G
Rationale: Beer , hypertension , diabetes, osteoarthritis increase uric acid levels or metabolic risks for gout.
History and Physical
A 59-year-old male client presents to the clinic reporting pain in the right great toe. The client says that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months. The client tells the nurses that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not improved and that he is unable to walk or work without excruciating pain in the great toe joint. The client has type 2 diabetes mellitus, osteoarthritis, hypertension, obesity, and sleep apnea. Currently, the client takes daily metformin, daily aspirin, daily enalapril, and ibuprofen as needed for pain. The client reports that he has never smoked or used tobacco products. He does not use recreational drugs. Typically, he drinks 2 to 3 dark beers nightly.
The healthcare provider is considering medications to treat the client's gout.
A 59-year-old male client presents to the clinic reporting pain in the right great toe. For each medication used to treat gout, choose the most likely therapeutic outcome and the teaching associated with the medication.
- A. Colchicine: Reduces inflammation.
- B. Prednisone: Reduces inflammation.
- C. Naproxen: Reduces pain and inflammation.
- D. Allopurinol: Lowers uric acid levels.
Correct Answer: A,B,C,D
Rationale: Colchicine and prednisone reduce inflammation, naproxen alleviates pain and inflammation, and allopurinol prevents uric acid buildup, addressing both acute and chronic gout management.
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
- A. The client's blood pressure reading will be less than 160/90 mm Hg.
- B. The client's daily blood pressure will be less than 140/80 mm Hg this month.
- C. The client's family will repeat signs and symptoms about the disease.
- D. The nurse will encourage the client to walk thirty minutes every day.
Correct Answer: B
Rationale: A blood pressure goal of less than 140/80 mm Hg is specific and aligns with cardiovascular health targets, addressing blurred vision linked to hypertension.