Nokea
What causes brown pigmentation of the lower extremities in clients with venous stasis?
- A. The necrosis of subcutaneous fat due to tissue hypoxia
- B. Breakdown of red blood cells in the congested tissues
- C. Reduced inflammatory and immune response from congested circulation
- D. Skin atrophy caused by lack of circulation
Correct Answer: B
Rationale: The brown pigmentation of the lower extremities in clients with venous stasis is primarily caused by the breakdown of red blood cells in the congested tissues. When there is venous stasis, the blood circulation is impaired, leading to a backup of blood in the lower extremities. This stagnant blood contains hemosiderin, a byproduct of red blood cell breakdown. Over time, the hemosiderin deposits in the tissues, causing the characteristic brown discoloration seen in conditions such as chronic venous insufficiency. This process is known as hemosiderin deposition and is a common consequence of venous stasis.
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An adult client is experiencing paroxysmal supraventricular tachycardia. Which nursing interventions are appropriate based on the data provided? Select all that apply.
- A. Initiate oxygen therapy
- B. Prepare for cardioversion
- C. Begin anticoagulation therapy as prescribed
- D. Administer intravenous adenosine as prescribed
Correct Answer: A
Rationale: A. Initiate oxygen therapy: Providing oxygen therapy is appropriate to ensure adequate oxygenation and tissue perfusion during episodes of paroxysmal supraventricular tachycardia.
The nurse is caring for an adult client who was diagnosed with a congenital heart defect as a child, which was later repaired with surgery. Which common complication of a heart defect should the nurse monitor that the client may still be at risk for?
- A. Deep vein thrombosis
- B. Endocarditis
- C. Atherosclerosis
- D. Shock
Correct Answer: B
Rationale: Endocarditis is a common complication that individuals with repaired congenital heart defects may still be at risk for. Endocarditis is an infection of the inner lining of the heart chambers and valves. The altered structure of the heart tissue from the previous defect and surgery can create an increased risk for bacterial growth and infection. Patients with a history of congenital heart defects should be monitored for signs and symptoms of endocarditis, such as fever, fatigue, new heart murmurs, and evidence of systemic embolization. Prophylactic antibiotics before certain dental and surgical procedures may be recommended to prevent endocarditis in this population. Therefore, the nurse should be vigilant in monitoring for any symptoms suggestive of endocarditis in this client.
The nurse evaluates teaching provided to a patient with a newly created ileal diversion with a continent reservoir. Which patient behavior indicates teaching has been effective?
- A. Demonstrates care for the collection device
- B. Demonstrates self-catheterization of the stoma
- C. Identifies factors contributing to the risk for bladder cancer
- D. States the importance of promptly reporting cloudy urine to the physician
Correct Answer: A
Rationale: In a patient with a newly created ileal diversion with a continent reservoir, demonstrating care for the collection device signifies that the patient has understood the importance of maintaining hygiene and proper management of the device. This behavior indicates that the teaching provided by the nurse has been effective in helping the patient take care of the diversion and prevent complications such as infection or skin irritation. Understanding how to care for the collection device is crucial for the patient's overall well-being and quality of life with the continent reservoir.
A client diagnosed with a deep vein thrombosis (DVT) is receiving intravenous heparin. Which is the priority outcome for this client?
- A. The client will not disturb the intravenous infusion.
- B. The client will comply with dietary restrictions.
- C. The client will not experience bleeding.
- D. The client will keep the right leg elevated on two pillows.
Correct Answer: C
Rationale: The priority outcome for a client with deep vein thrombosis (DVT) receiving intravenous heparin is to prevent bleeding. Heparin is an anticoagulant medication used to prevent the formation of blood clots, but one of its potential side effects is bleeding due to its ability to prevent blood clotting. It is crucial to closely monitor the client for signs of bleeding while on heparin therapy, such as easy bruising, black or tarry stools, blood in the urine, or excessive bleeding from wounds. Preventing bleeding is essential to avoid complications associated with anticoagulant therapy.
A patient has developed a paralytic ileus following recent abdominal surgery. What is the most important nursing action when caring for this patient?
- A. Monitor bowel sounds every hour
- B. Maintain the patient on strict bed rest
- C. Ensure the nasogastric tube is functioning
- D. Ensure that the patient is given a clear liquid diet
Correct Answer: C
Rationale: Ensuring that the nasogastric tube is functioning is the most important nursing action when caring for a patient with a paralytic ileus. A paralytic ileus is a condition where there is a temporary paralysis of the intestine, leading to a lack of bowel motility. This can result in a buildup of gas and fluids in the intestines, causing abdominal distension, pain, and potential complications.