Nokea
When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
- A. Decreased blood volume
- B. Increase in muscular activity
- C. Increased venous pressure
- D. Increased arterial pressure
Correct Answer: C
Rationale: Bilateral ankle edema in PVD is often due to increased venous pressure from venous insufficiency or right-sided heart failure, which impairs venous return and causes fluid to pool in the lower extremities. Decreased blood volume or increased muscular activity does not cause edema, and arterial pressure is not directly related.
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Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy?
- A. Pains in the joints of the hands and feet.
- B. Tingling in the fingers.
- C. Bleeding on the back of the dressing.
- D. Tension on the suture line.
Correct Answer: B
Rationale: Tetany, caused by hypocalcemia from parathyroid gland damage during thyroidectomy, presents with tingling in the fingers, muscle cramps, or spasms.
The nurse has received a prescription for tenofovir and emtricitabine. The nurse understands that this medication is used to treat
- A. multiple sclerosis.
- B. human immunodeficiency virus (HIV).
- C. Parkinson's disease.
- D. Guillain-Barré syndrome.
Correct Answer: B
Rationale: Tenofovir and emtricitabine (Truvada) are antiretroviral medications used to treat and prevent HIV. They are not used for multiple sclerosis (A), Parkinson’s disease (C), or Guillain-Barré syndrome (D).
A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. Which action should be the nurse's first response?
- A. Assess for potential abuse.
- B. Check for diminished sensations.
- C. Document the findings.
- D. Clean and dress the area.
Correct Answer: B
Rationale: Macrocytic anemia, often due to vitamin B12 or folate deficiency, can cause peripheral neuropathy, leading to diminished sensations and increased risk of burns from prolonged heat exposure. The nurse's first action should be to check for sensory deficits to assess the underlying cause of the injury. Assessing for abuse, documenting, or dressing the wound are secondary actions.
The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
- A. Administration of intravenous Octreotide (Sandostatin).
- B. Endoscopy.
- C. Administration of a blood product.
- D. Minnesota tube insertion.
- E. Transjugular intrahepatic portosystemic shunt (TIPS).
Correct Answer: A,B,C,D
Rationale: Octreotide (A) reduces portal pressure, endoscopy (B) diagnoses/treats bleeding, blood products (C) address hypovolemia, and Minnesota tube (D) controls bleeding. TIPS (E) is a later intervention, not immediate.
After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. Which of the following is an expected outcome of these exercises?
- A. Deep breathing elevates the diaphragm, which enlarges the thorax and increases the lung surface available for gas exchange.
- B. Deep breathing increases blood flow to the lungs to allow them to recover from the trauma of surgery.
- C. Deep breathing controls the rate of air flow to the remaining lobe so that it will not become hyperinflated.
- D. Deep breathing expands the alveoli and increases the lung surface available for ventilation.
Correct Answer: D
Rationale: Deep breathing expands alveoli, increasing lung surface for ventilation and preventing atelectasis post-thoracotomy. It does not elevate the diaphragm, increase blood flow, or control airflow to prevent hyperinflation.