Nokea
What should be included in foot care for the client who has a peripheral vascular disorder?
- A. Soaking the feet for 20 minutes before washing them
- B. Walking barefoot only on carpeted floors
- C. Applying lotion between the toes to avoid cracking of the skin
- D. Avoiding exposure of the legs and feet to the sun
Correct Answer: D
Rationale: Avoiding sun exposure prevents skin damage in clients with compromised circulation due to peripheral vascular disease. Soaking, walking barefoot, or applying lotion between toes increase infection or injury risk.
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A male client with angina pectoris has been having an increased number of episodes of pain recently. He is admitted for observation. During the admission interview, he tells the nurse that he has been having chest pain during the last week. Which statement by the client would be of greatest concern to the nurse?
- A. I had chest pain while I was walking in the snow on Thursday.'
- B. We went out for a big dinner to celebrate my wife's birthday, but I couldn't enjoy it because I got the pain before we got home from the restaurant.'
- C. I had chest pain yesterday while I was sitting in the living room watching television.'
- D. I felt pain all the way down my left arm after I was playing with my grandson on Monday.'
Correct Answer: C
Rationale: Chest pain at rest, such as while watching television, is concerning as it may indicate unstable angina or impending myocardial infarction, requiring urgent evaluation. Pain with activity, eating, or radiating to the arm is typical of angina but less immediately alarming.
Which data would cause the nurse to question administering digoxin to a client diagnosed with congestive heart failure?
- A. The potassium level is 3.2 mEq/L.
- B. The digoxin level is 1.2 mcg/mL.
- C. The client's apical pulse is 64.
- D. The client denies yellow haze.
Correct Answer: A
Rationale: Hypokalemia (K+ 3.2, A) increases digoxin toxicity risk, warranting caution. Digoxin level 1.2 (B) is therapeutic, pulse 64 (C) is normal, and no yellow haze (D) is expected.
The telemetry nurse notes a peaked T wave for the client diagnosed with congestive heart failure. Which laboratory data should the nurse assess?
- A. CK-MB.
- B. Troponin.
- C. BNP.
- D. Potassium.
Correct Answer: D
Rationale: Peaked T waves indicate hyperkalemia; assessing potassium (D) is critical in CHF patients on diuretics. CK-MB (A) and troponin (B) are for MI, BNP (C) for heart failure severity.
Which assessment finding would support the possibility of right-sided heart failure?
- A. Jugular vein distention
- B. Bradycardia
- C. Dry, hacking cough
- D. Flushed, red face
Correct Answer: A
Rationale: Jugular vein distention indicates increased venous pressure, typical of right-sided heart failure.
An adult is diagnosed with hypertension. He is prescribed chlorothiazide (Diuril) 500 mg PO. What nursing instruction is essential for him?
- A. Drink at least two quarts of liquid daily.
- B. Avoid hard cheeses.
- C. Drink orange juice or eat a banana daily.
- D. Do not take aspirin.
Correct Answer: C
Rationale: Chlorothiazide, a diuretic, can cause potassium loss. Consuming potassium-rich foods like orange juice or bananas helps prevent hypokalemia.