Nokea
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.
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Upon assessing the client who has distal foot pain due to vascular insufficiency, the nurse notes the wound illustrated. When reviewing the client’s medical record, which notation is the nurse likely to find?
- A. Venous ulcer on left foot
- B. Arterial ulcer on right foot
- C. Diabetic ulcer on left foot
- D. Stress ulcer on right foot
Correct Answer: B
Rationale: The nurse should find a notation of an arterial ulcer on the right foot. Arterial ulcers typically occur on the feet; they are deep, and the ulcer bed is pale with even, defined edges and limited granulation tissue. Venous ulcers are at the ankle, diabetic ulcers are plantar, and stress ulcers are gastric.
The client is discovered to have a popliteal aneurysm. Because of the aneurysm, the nurse should closely monitor the client for which associated problem?
- A. Thoracic outlet syndrome
- B. Ischemia in the lower limb
- C. Pulmonary embolism
- D. Raynaud’s phenomenon
Correct Answer: B
Rationale: A popliteal aneurysm (located in the space behind the knee) may cause ischemia in the leg distal to the aneurysm due to thrombus forming inside the aneurysm and potential emboli. Other options are unrelated to popliteal aneurysms.
The client, returning from a coronary catheterization in which the femoral artery approach was used, sneezes. Which should be the nurse’s priority intervention?
- A. Palpate pedal pulses
- B. Measure vital signs
- C. Assess for urticaria
- D. Check the insertion site
Correct Answer: D
Rationale: Checking the insertion site is priority. Sneezing increases intra-abdominal pressure and increases the risk for clot disruption and bleeding from the femoral artery. Pedal pulses, vital signs, and urticaria are secondary concerns.
The nurse is teaching the client newly diagnosed with chronic stable angina. Which instructions on measures to prevent future angina should the nurse incorporate? Select all that apply.
- A. Increase isometric arm exercises to build endurance.
- B. Wear a facemask when outdoors in cold weather.
- C. Take nitroglycerin before a stressful event even if pain free.
- D. Perform most exertional activities in the morning.
- E. Take a daily laxative to avoid straining with bowel movements.
- F. Discontinue use of all tobacco products if you use these.
Correct Answer: B;C;F
Rationale: The nurse should instruct: B) Wearing a facemask in cold weather to prevent vasoconstriction; C) Taking nitroglycerin prophylactically to improve coronary blood flow; F) Discontinuing tobacco to reduce vasoconstriction. Isometric exercises, morning exertion, and daily laxatives are not recommended as they may increase cardiac workload or cause other issues.
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.