Nokea
The nurse is taking the BP on multiple clients. Which reading warrants the nurse notifying the HCP because the client’s MAP is abnormal?
- A. 94/60 mm Hg
- B. 98/36 mm Hg
- C. 110/50 mm Hg
- D. 140/78 mm Hg
Correct Answer: B
Rationale: The Mean Arterial Pressure (MAP) is calculated as (SBP + 2*DBP)/3. For 98/36 mm Hg: (98 + 2*36)/3 = (98 + 72)/3 = 170/3 ≈ 56.67 mm Hg, which is abnormally low (normal MAP is 70-100 mm Hg), indicating potential hypoperfusion. Other readings yield: A: (94 + 2*60)/3 ≈ 71.33 mm Hg, C: (110 + 2*50)/3 ≈ 70 mm Hg, D: (140 + 2*78)/3 ≈ 98.67 mm Hg, all within or closer to normal range.
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The clinic nurse is teaching the client at risk for developing arteriosclerosis. The nurse should teach the client that the dietary therapy to decrease homo-cysteine levels includes eating foods rich in which nutrient?
- A. Monosaturated fats
- B. B complex Vitamins
- C. Vitamin C
- D. Calcium
Correct Answer: B
Rationale: Homocysteine interferes with the elasticity of the endothelial layer in blood vessels. Foods rich in B-complex vitamins, especially folic acid, have been found to lower serum homocysteine levels. Monosaturated fats, Vitamin C, and Calcium do not have a direct effect on homocysteine levels.
The nurse is caring for the client with varicose veins. Which action should indicate to the nurse that an expected outcome has been met?
- A. States will walk daily to promote venous return
- B. Reports decreased need for compression stockings
- C. States can finally stand for prolonged periods of time
- D. Chooses diet high in potassium and low in magnesium
Correct Answer: A
Rationale: Walking promotes venous return; verbalizing intent to increase activity indicates an expected outcome has been met for the client with varicose veins. Decreased stocking use, prolonged standing, and specific diets are not beneficial.
The nurse is assessing the client with an 8-centimeter AAA. Which finding should the nurse expect?
- A. Report of persistent nagging pain in the upper anterior chest
- B. Systolic bruit palpated over the upper abdomen
- C. Edema of the face and neck with distended neck veins
- D. A pulsating mass in the mid to upper abdomen
Correct Answer: D
Rationale: Throbbing or pulsating in the abdomen is the sign most indicative of an AAA. Chest pain, edema, and neck vein distention are associated with thoracic aneurysms, and a bruit is auscultated, not palpated.
The nurse is caring for the client who had a cardiac valve replacement. To decrease the risk of DVT and PE, which interventions should the nurse plan to include? Select all that apply.
- A. Apply a pneumatic compression device.
- B. Administer a heparin infusion intravenously.
- C. Encourage coughing and deep breathing hourly.
- D. Teach about performing isometric leg exercises.
- E. Avoid the use of graded compression elastic stockings.
Correct Answer: A;D
Rationale: The nurse should include: A) Pneumatic compression devices to mimic walking pressures; D) Isometric exercises to compress vessels and reduce DVT risk. Heparin is typically subcutaneous, coughing/deep breathing prevents pulmonary issues, and compression stockings are beneficial unless PAD is present.
The nurse reviews symptoms of acute graft occlusion with the client who has had a revascularization graft procedure of the lower extremity. Which symptom of acute arterial occlusion stated by the client indicates the need for further teaching?
- A. Severe pain
- B. Paresthesia
- C. Warm and red incisions
- D. Inability to move the foot
Correct Answer: C
Rationale: Redness and warmth along the incision line are associated with inflammation or infection, not graft occlusion. Severe pain, paresthesia, and inability to move the foot are symptoms of acute arterial occlusion, indicating the client needs further teaching about incision symptoms.