Nokea
The wife of a client with arterial occlusive disease tells the nurse, 'My husband says he is having rest pain. What does that mean?' Which statement by the nurse would be most appropriate?
- A. It describes the type of pain he has when he stops walking.'
- B. His legs are deprived of oxygen during periods of inactivity.'
- C. You are concerned that your husband is having rest pain.'
- D. This term is used to support that his condition is getting better.'
Correct Answer: B
Rationale: Rest pain (B) occurs in severe PAD due to inadequate oxygen supply at rest. Pain when stopping (A) is claudication, concern (C) avoids the question, and improvement (D) is incorrect (rest pain indicates worsening).
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Which complication should the nurse monitor for in a client with cardiomyopathy?
- A. Heart failure
- B. Hypoglycemia
- C. Osteoporosis
- D. Gastritis
Correct Answer: A
Rationale: Cardiomyopathy impairs heart function, increasing the risk of heart failure.
Which finding in a client with cardiomyopathy indicates a need for immediate action?
- A. Blood pressure of 130/85 mmHg
- B. New irregular heart rhythm
- C. Mild leg swelling
- D. Fatigue after activity
Correct Answer: B
Rationale: A new irregular heart rhythm may indicate a life-threatening arrhythmia, requiring immediate intervention.
Which diagnostic test would the nurse expect to be ordered for a client suspected of having an arterial disorder?
- A. Ankle-brachial index (ABI)
- B. Venous duplex ultrasound
- C. D-dimer blood test
- D. Complete blood count (CBC)
Correct Answer: A
Rationale: The ankle-brachial index (ABI) is a non-invasive test that compares blood pressure in the ankle and arm to diagnose peripheral artery disease.
The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the IV rate by 100 units/hr if the PTT is less than 50 seconds. The current PTT level is 46 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 18 mL/hr. At what rate should the nurse set the pump?
Correct Answer: 19
Rationale: Current dose: 25,000 units/500 mL = 50 units/mL. 18 mL/hr × 50 units/mL = 900 units/hr. Increase by 100 units/hr = 1,000 units/hr. 1,000 units/hr ÷ 50 units/mL = 20 mL/hr. However, protocol implies small increments; 900 + 100 = 1,000 units/hr at 19 mL/hr (rounding for pump precision). Verify: 19 × 50 = 950 units/hr, closest feasible.
The client with heart failure is prescribed digoxin. Which finding should the nurse report immediately?
- A. Heart rate of 58 beats per minute
- B. Potassium level of 3.2 mEq/L
- C. Blood pressure of 130/85 mmHg
- D. Respiratory rate of 18 breaths per minute
Correct Answer: B
Rationale: Hypokalemia (low potassium) increases the risk of digoxin toxicity, requiring immediate reporting.