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The unlicensed assistive personnel (UAP) is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse?
- A. Removing compression stockings before assisting the client to bed.
- B. Taking the client’s blood pressure manually after using the machine.
- C. Assisting the client by opening the milk carton on the lunch tray.
- D. Calculating the client’s shift intake and output with a pen and paper.
Correct Answer: A
Rationale: Removing compression stockings (A) at night is incorrect; they should be worn to reduce edema. Manual BP (B), opening cartons (C), and I/O Calculation(ans only)s (D) are appropriate.
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Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy?
- A. Walk 15 to 20 minutes three (3) times a day.
- B. Keep the legs in the dependent position when sitting.
- C. Remove compression bandages before going to bed.
- D. Perform Buerger-Allen exercises four (4) times a day.
Correct Answer: A
Rationale: Walking 15–20 minutes 3×/day (A) promotes venous return post-sclerotherapy. Dependent position (B) worsens pooling, bandages (C) stay on, and Buerger-Allen (D) is for arterial disease.
Which complication should the nurse monitor for in a client with valvular heart disease?
- A. Pulmonary embolism
- B. Heart failure
- C. Liver failure
- D. Pneumonia
Correct Answer: B
Rationale: Valvular heart disease can lead to heart failure due to increased cardiac workload and impaired pump function.
The intensive care department nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 880 mL of D5W, IVPB of 100 mL of 0.9% NS, 8 ounces of water, 4 ounces of milk, and 6 ounces of chicken broth. The client has had a urinary output of 1,480 mL. What is the total intake for this client?
Correct Answer: 1180
Rationale: Total intake = IV fluids (880 mL D5W + 100 mL NS) + oral fluids (8 oz water + 4 oz milk + 6 oz broth). 1 oz = 30 mL, so oral = (8+4+6) × 30 = 540 mL. Total = 880 + 100 + 540 = 1,180 mL. Output (1,480 mL) is not included in intake.
The nurse is teaching a client about home blood pressure monitoring. Which instruction is most important?
- A. Take your blood pressure at the same time each day.
- B. Use a wrist cuff for the most accurate readings.
- C. Sit with your legs crossed during measurement.
- D. Check your blood pressure only when you feel ill.
Correct Answer: A
Rationale: Consistency in timing ensures accurate trending of blood pressure readings.
When assessing the client's lower leg, which findings characteristic of venous stasis ulcers is the nurse most likely to find? Select all that apply.
- A. Purulent drainage from lesions
- B. Blanched patches around open areas
- C. Dark brown, dry, and crusty skin
- D. Fluid-filled blisters
- E. Edema in the lower legs
- F. Fine red rash below the knee
Correct Answer: C,E
Rationale: Venous stasis ulcers are typically characterized by dark brown, dry, crusty skin due to hemosiderin deposition and edema in the lower legs due to venous insufficiency.