Nokea
The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first?
- A. Complete a neurovascular assessment.
- B. Use the Doppler device.
- C. Instruct the client to hang the feet off the side of the bed.
- D. Wrap the legs in a blanket.
Correct Answer: B
Rationale: Absent pedal pulse in PAD requires Doppler use (B) to confirm blood flow. Neurovascular assessment (A) follows, dependent position (C) worsens ischemia, and blankets (D) are irrelevant.
You may also like to solve these questions
Which intervention should the nurse prioritize for a client with heart failure experiencing shortness of breath?
- A. Administer oxygen as prescribed.
- B. Place the client in a supine position.
- C. Encourage deep breathing exercises.
- D. Restrict all fluid intake.
Correct Answer: A
Rationale: Administering oxygen improves oxygenation in clients with shortness of breath due to heart failure.
Which teaching point should the nurse include for a client with coronary artery disease? Select all that apply.
- A. Exercise regularly as tolerated.
- B. Avoid all fats in the diet.
- C. Manage stress effectively.
- D. Take medications as prescribed.
- E. Monitor for chest pain.
- F. Limit physical activity.
Correct Answer: A,C,D,E
Rationale: Regular exercise, stress management, medication adherence, and monitoring for chest pain reduce complications in coronary artery disease.
Which signs/symptoms would the nurse expect to find when assessing a client diagnosed with subclavian steal syndrome?
- A. Complaints of arm tiredness with exertion.
- B. Complaints of shortness of breath while resting.
- C. Jugular vein distention when sitting at a 35-degree angle.
- D. Dilated blood vessels above the nipple line.
Correct Answer: A
Rationale: Subclavian steal syndrome causes arm ischemia due to subclavian artery occlusion, leading to arm tiredness with exertion (A). Shortness of breath (B), JVD (C), and dilated vessels (D) are not typical.
The nurse is teaching a class on coronary artery disease. Which modifiable risk factor should the nurse discuss when teaching about atherosclerosis?
- A. Stress.
- B. Age.
- C. Gender.
- D. Family history.
Correct Answer: A
Rationale: Stress (A) is a modifiable risk factor for atherosclerosis (e.g., via lifestyle changes). Age (B), gender (C), and family history (D) are non-modifiable.
The nurse is teaching a client with cardiomyopathy about implantable cardioverter-defibrillators (ICDs). Which statement is accurate?
- A. It will prevent all arrhythmias.
- B. It delivers a shock if a dangerous rhythm occurs.
- C. It replaces the need for medications.
- D. It requires replacement every 2 years.
Correct Answer: B
Rationale: An ICD monitors heart rhythm and delivers a shock to restore normal rhythm in life-threatening arrhythmias.