Nokea
The nurse is working with a client who has just been diagnosed with an aneurysm. What advice should the nurse provide to this client?
- A. Minimize bowel movements and coughing
- B. Avoid situations that contribute to ischemic episodes
- C. Avoid straining during bowel movements and coughing
- D. Wear wool socks and mittens during cold weather
Correct Answer: C
Rationale: The nurse advises the client with an aneurysm to avoid straining during bowel movements and coughing. Coughing and straining increase the risk of rupture. The client with Raynaud syndrome is asked to avoid situations that contribute to ischemic episodes and to wear wool socks and mittens during cold weather.
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The nurse is caring for a client who is suspected of having coronary artery disease. The client is scheduled to have a nuclear stress test using thallium. When would the thallium be injected to determine narrowing of the coronary arteries?
- A. During and a few hours after exercise electrocardiography
- B. Before and during exercise electrocardiography
- C. Before and a few hours after exercise electrocardiography
- D. Before, during, and a few hours after exercise electrocardiography
Correct Answer: A
Rationale: A nuclear stress test using a radionuclide, such as thallium, may be injected intravenously (IV) during and a few hours after exercise electrocardiography, followed by a heart scan. Narrowing of one or more coronary arteries is documented during coronary arteriography.
The nurse is caring for a client who is status postoperative from a vein stripping. What would the nurse monitor for in the client?
- A. Swelling in the inoperative leg
- B. Blood on the dressing on the inoperative leg
- C. Warm, pink toes in the inoperative leg
- D. Swelling in the operative leg
Correct Answer: D
Rationale: When the client returns from surgery with a gauze dressing covered by elastic roller bandages on the operative leg, the nurse monitors for swelling in the operative leg(s) and its effect on circulation.
A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction?
- A. Pallor
- B. Cyanosis
- C. Gangrene
- D. Ulceration
Correct Answer: A
Rationale: Pallor is the initial symptom in Raynaud syndrome followed by cyanosis and aching pain. Gangrene and ulceration can occur with persistent attacks and interference of blood flow.
Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty?
- A. Inform client of diagnostic tests
- B. Remove hair from skin insertion sites
- C. Assess distal pulses
- D. Withhold anticoagulant therapy
Correct Answer: D
Rationale: The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not the most important action to be taken.
A client presents to the emergency room with characteristics of atherosclerosis. What characteristics would the client display?
- A. Fatty deposits in the lumen of arteries
- B. Cholesterol plugs in the lumen of veins
- C. Blood clots in the arteries
- D. Emboli in the veins
Correct Answer: A
Rationale: Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque. Therefore, the other options are incorrect.