Nokea
When the nurse is planning the client's postoperative care, which action is the highest priority?
- A. Providing the client with protein-rich foods
- B. Ambulating the client frequently
- C. Monitoring for wound infection
- D. Assessing for frequent leg cramping
Correct Answer: C
Rationale: Monitoring for wound infection is critical post-surgery to prevent complications and ensure healing.
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The nurse and an unlicensed assistive personnel (UAP) are bathing a bedfast client. Which action by the UAP warrants immediate intervention?
- A. The UAP closes the door and cubicle curtain before undressing the client.
- B. The UAP begins to massage and rub lotion into the client’s calf.
- C. The UAP tests the temperature of the water with the wrist before starting.
- D. The UAP collects all the linens and supplies and brings them to the room.
Correct Answer: B
Rationale: Massaging calves (B) risks dislodging a clot in a bedfast client (high DVT risk). Privacy (A), water testing (C), and supplies (D) are appropriate.
The client with atrial fibrillation is prescribed warfarin. Which laboratory value should the nurse monitor?
- A. Platelet count
- B. International normalized ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Red blood cell count
Correct Answer: B
Rationale: Warfarin's anticoagulant effect is monitored using INR to ensure therapeutic levels and prevent bleeding or clotting.
The client with hypertension asks why they need to limit stress. What is the best response?
- A. Stress causes fluid retention.
- B. Stress increases your heart rate and blood pressure.
- C. Stress reduces oxygen to your heart.
- D. Stress weakens your immune system.
Correct Answer: B
Rationale: Stress activates the sympathetic nervous system, increasing heart rate and blood pressure.
The health-care provider prescribes an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with essential hypertension. Which statement is the most appropriate rationale for administering this medication?
- A. ACE inhibitors prevent beta receptor stimulation in the heart.
- B. This medication blocks the alpha receptors in the vascular smooth muscle.
- C. ACE inhibitors prevent vasoconstriction and sodium and water retention.
- D. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle.
Correct Answer: C
Rationale: ACE inhibitors block angiotensin II, preventing vasoconstriction and sodium/water retention (C), thus lowering BP. Beta (A) and alpha (B) receptors are unrelated, and smooth muscle relaxation (D) is a secondary effect.
The nurse is assessing the client diagnosed with long-term arterial occlusive disease. Which assessment data support the diagnosis?
- A. Hairless skin on the legs.
- B. Brittle, flaky toenails.
- C. Petechiae on the soles of feet.
- D. Nonpitting ankle edema.
Correct Answer: A
Rationale: Hairless skin (A) indicates chronic ischemia in PAD. Brittle nails (B) are nonspecific, petechiae (C) suggest bleeding, and nonpitting edema (D) is unrelated (pitting edema is venous).