Nokea
The nurse is planning care for a client with a history of peripheral vascular disease who has symptoms of claudication. Nursing care should be directed to avoiding which of the following situations?
- A. Oxygen demand by the muscle exceeds the supply
- B. Oxygen demand and supply of the working muscle are in balance
- C. Oxygen supply exceeds the demand of the working muscle
- D. Oxygen is absent
Correct Answer: A
Rationale: Claudication in PVD results from insufficient blood flow to muscles during activity, causing oxygen demand to exceed supply, leading to pain. Nursing care should aim to improve blood flow (e.g., through exercise programs or medications) and avoid situations where muscle oxygen demand outstrips supply. Balanced or excess supply is desirable, and complete oxygen absence is not typical in claudication.
You may also like to solve these questions
The client with type 1 diabetes mellitus is taught to take NPH insulin at 5 p.m. each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time?
- A. 11 a.m., shortly before lunch.
- B. 1 p.m., shortly after lunch.
- C. 6 p.m., shortly after dinner.
- D. 1 a.m., while sleeping.
Correct Answer: D
Rationale: NPH insulin peaks 4–12 hours after administration (around 9 p.m. to 5 a.m.), with the greatest hypoglycemia risk overnight, such as at 1 a.m.
The nurse is teaching a client who is scheduled for a transfusion of one unit of packed red blood cells (PRBCs). Which of the following information should the nurse include?
- A. A baseline weight will be taken before the start of the transfusion.
- B. I will be with you during the transfusion's first fifteen minutes.
- C. You will need to provide a urine sample at the end of the transfusion.
- D. Please complete the required surgical consent before the transfusion.
Correct Answer: B
Rationale: The nurse must stay with the client during the first 15 minutes of a PRBC transfusion to monitor for acute reactions, which are most likely to occur early. Baseline weight is relevant for fluid overload risk, not routine. Urine samples are not standard, and surgical consent is not required for transfusions.
A client with cancer develops superior vena cava syndrome (SVCS). Which of the following symptoms should the nurse assess for?
- A. Facial swelling and dyspnea.
- B. Lower extremity edema.
- C. Abdominal distension.
- D. Flank pain.
Correct Answer: A
Rationale: SVCS obstructs venous return, causing facial swelling and dyspnea due to compression of the superior vena cava, which the nurse should prioritize in assessment.
A client is scheduled to have an elective mandibular osteotomy to correct a mandibular fracture sustained in an accident 6 months earlier. Which statement by the client indicates to the nurse maladaptive coping?
- A. œI will be glad to have my jaw fixed because my wife thinks I do not look like myself.'
- B. œI am somewhat afraid to have the surgery but feel OK about it.'
- C. œMy wife will help me, but I don't think I will need that much help.'
- D. œI am ready to get this over with.'
Correct Answer: A
Rationale: The statement about the wife's perception suggests the client's motivation is external and may reflect poor self-image or reliance on others' opinions, indicating maladaptive coping. The other statements show acceptance, realistic fear, or confidence, which are more adaptive.
When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift the patient.
- A. While inhaling through an open mouth.
- B. While exhaling through pursed lips.
- C. After exhaling but before inhaling.
- D. While taking a deep breath and holding it.
Correct Answer: B
Rationale: Lifting while exhaling through pursed lips conserves energy by aligning effort with prolonged exhalation, reducing air trapping in COPD. Other methods increase respiratory workload.