Nokea
The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should:
- A. Apply a half-leg pneumatic compression device
- B. Suggest the client contact her physician
- C. Assess the client for foot ulcers
- D. Encourage the client to avoid standing in one position for long periods of time
Correct Answer: D
Rationale: Distended, tortuous veins suggest varic varicose veins. Avoiding prolonged standing reduces venous pooling and symptom progression. Applying compression devices requires a prescription, contacting a physician is premature, and foot ulcers are not indicated by the description.
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A client with a spinal cord injury is at risk for pressure ulcers. Which nursing intervention is most effective?
- A. Reposition the client every 4 hours.
- B. Use a foam mattress without a cover.
- C. Apply lotion to bony prominences daily.
- D. Turn the client every 2 hours.
Correct Answer: D
Rationale: Turning every 2 hours redistributes pressure, preventing ulcer formation in immobilized clients.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 2 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
For each client finding below, click to specify if the finding is consistent with the disease process of heat exhaustion or heat stroke. Each finding may support more than 1 disease process.
- A. Temperature 105° F (40.5° C)
- B. Confusion
- C. Perspiration
- D. Tachycardia
- E. Signs of dehydration
- F. Hypotension
Correct Answer: A,B,C,D,E,F
Rationale: A (Heat Stroke), B (Heat Stroke), C (Heat Exhaustion), D (Both), E (Both), F (Both). Temperature 104°F and confusion are hallmark signs of heat stroke. Perspiration is typical in heat exhaustion but absent in heat stroke. Tachycardia, dehydration, and hypotension occur in both conditions due to heat stress.
The nurse is assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning. Which of the following would pose the greatest hazard to the client as a risk for falling at home?
- A. A 4-year-old cocker spaniel.
- B. Scatter rugs.
- C. Snack tables.
- D. Rocking chairs.
Correct Answer: B
Rationale: Scatter rugs are a significant fall risk due to tripping hazards.
The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to do which of the following?
- A. Use herbal supplements.
- B. Eat a diet high in protein and vitamins C and D.
- C. Ask the health care provider for a change of antibiotics.
- D. Encourage frequent passive range-of-motion to the affected extremity.
Correct Answer: B
Rationale: A diet high in protein and vitamins C and D supports tissue healing and immune function in osteomyelitis.
A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should first:
- A. Review the results of culture and sensitivity testing of the wound.
- B. Look for the presence of a pressure dressing over the wound.
- C. Determine if the client has increased pain from exposed nerve endings.
- D. Check the client's blood pressure for hypotension resulting from additional vessel bleeding.
Correct Answer: D
Rationale: Checking blood pressure for hypotension is the priority, as bleeding from an open fracture can be life-threatening.