Nokea
The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to:
- A. Decreased blood flow
- B. Increased blood flow
- C. Increased blood viscosity
- D. Increased blood viscosity
Correct Answer: A
Rationale: In PVD, decreased blood flow to the extremities limits oxygen delivery to muscles, reducing exercise tolerance. In heart failure, reduced cardiac output further exacerbates this limitation, as the heart cannot meet increased oxygen demands during activity. Increased blood flow or viscosity is not relevant, and the options are repeated incorrectly in the document.
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The nurse is assessing a client post-laminectomy for complications. Which finding requires immediate action?
- A. Mild incisional pain.
- B. Clear drainage from the incision.
- C. Slight numbness in the toes.
- D. Stable vital signs.
Correct Answer: B
Rationale: Clear drainage may indicate a cerebrospinal fluid leak, a critical complication requiring urgent intervention.
A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply.
- A. Angel food cake.
- B. Banana.
- C. Dried fruit.
- D. Orange juice.
- E. Peppers.
Correct Answer: B,C,D
Rationale: Loop diuretics like furosemide cause potassium loss. Bananas (B), dried fruit (C), and orange juice (D) are potassium-rich, helping prevent hypokalemia.
A 36-year-old female is complaining of increased vaginal dryness during sexual intercourse. She has received chemotherapy in the past and has menopausal symptoms due to ovarian suppression. An appropriate nursing intervention would be to instruct the client on the use of:
- A. Vaginal dilators.
- B. Nightly douches.
- C. Water-soluble vaginal lubricants.
- D. Relaxation techniques.
Correct Answer: C
Rationale: Water-soluble vaginal lubricants are effective for managing vaginal dryness caused by chemotherapy-induced ovarian suppression, improving comfort during intercourse.
A nurse is assessing a client with Addison's disease. The nurse should review laboratory reports for which of the following?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Decreased blood urea nitrogen (BUN) level.
Correct Answer: C
Rationale: Hypoglycemia is common in Addison's disease due to cortisol deficiency, which impairs gluconeogenesis.
A client with uric acid stones is prescribed a low-purine diet. Which food is allowed?
- A. Liver.
- B. Chicken.
- C. Apples.
- D. Sardines.
Correct Answer: C
Rationale: Apples are low in purines, suitable for a uric acid stone diet.