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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.
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The nurse is teaching the client about risk factors for arterial disorders. Which modifiable risk factor should the nurse emphasize?
- A. Age over 60 years
- B. Family history of heart disease
- C. Smoking cigarettes
- D. Male gender
Correct Answer: C
Rationale: Smoking is a modifiable risk factor that significantly contributes to arterial disorders by causing vasoconstriction and endothelial damage.
The nurse is demonstrating the use of a blood pressure sphygmomanometer to a client newly diagnosed with hypertension. Which should the nurse teach the client? Select all that apply.
- A. Tell the client to make sure the cuff is placed over an artery.
- B. Teach the client to notify the health-care provider if the BP is >160/100.
- C. Instruct the client about orthostatic hypotension.
- D. Encourage the client to keep a record of the blood pressure readings.
- E. Explain that even when the blood pressure is within normal limits the medication should still be taken.
Correct Answer: A,B,C,D,E
Rationale: Cuff over artery (A), notifying HCP for BP >160/100 (B), orthostatic precautions (C), BP log (D), and continuing meds (E) ensure proper BP management. All apply.
Which health-care provider’s order should the nurse question in a client diagnosed with an expanding abdominal aortic aneurysm who is scheduled for surgery in the morning?
- A. Type and crossmatch for two (2) units of blood.
- B. Tap water enema until clear fecal return.
- C. Bedrest with bathroom privileges.
- D. Keep nothing by mouth (NPO) after midnight.
Correct Answer: B
Rationale: Enemas (B) risk increasing intra-abdominal pressure, dangerous in expanding AAA. Blood crossmatch (A), bedrest (C), and NPO (D) are appropriate pre-surgery.
The nurse is caring for a client who is receiving heparin therapy intravenously. Which assessment data would indicate to the nurse the client is developing heparin-induced thrombocytopenia (HIT)? Select all that apply.
- A. The client has spontaneous bleeding from around the IV site.
- B. The client complains of chest pain on inspiration and has become restless.
- C. The client’s platelet count on admission was 420 (103) and now is 200 (103).
- D. The client complains that the gums bleed when brushing the teeth.
- E. The client has developed skin lesions at the IV site.
Correct Answer: A,C,D
Rationale: HIT causes thrombocytopenia and bleeding: IV site bleeding (A), platelet drop from 420 to 200 (C), and gum bleeding (D) are signs. Chest pain/restlessness (B) suggests PE, and skin lesions (E) are not typical.
Which instruction should the nurse include when providing discharge instructions to a client diagnosed with peripheral arterial disease?
- A. Encourage the client to use a heating pad on the lower extremities.
- B. Demonstrate to the client the correct way to apply elastic support hose.
- C. Instruct the client to walk daily for at least 30 minutes.
- D. Tell the client to check both feet for red areas at least once a week.
Correct Answer: C
Rationale: Daily walking for 30 minutes (C) promotes collateral circulation in PAD. Heating pads (A) risk burns, elastic hose (B) are for venous disease, and weekly checks (D) are insufficient (daily needed).