Nokea
Which assessment data would cause the nurse to suspect the client has atherosclerosis?
- A. Change in bowel movements.
- B. Complaints of a headache.
- C. Intermittent claudication.
- D. Venous stasis ulcers.
Correct Answer: C
Rationale: Intermittent claudication (C) indicates arterial insufficiency from atherosclerosis. Bowel changes (A) and headaches (B) are nonspecific, and venous ulcers (D) are venous-related.
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The client is four (4) hours postoperative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?
- A. Assist the client to ambulate.
- B. Assess the client's bilateral pedal pulses.
- C. Maintain a continuous IV heparin drip.
- D. Provide a clear liquid diet to the client.
Correct Answer: B
Rationale: Assessing pedal pulses (B) monitors graft patency post-AAA repair, critical at 4 hours. Ambulation (A) is premature, heparin (C) is not routine, and diet (D) awaits bowel function.
The nurse is teaching the client diagnosed with arterial occlusive disease. Which interventions should the nurse include in the teaching? Select all that apply.
- A. Wash legs and feet daily in warm water.
- B. Apply moisturizing cream to feet.
- C. Buy shoes in the morning hours only.
- D. Do not wear any type of knee stocking.
- E. Wear clean white cotton socks.
Correct Answer: A,B,D,E
Rationale: Washing feet (A), moisturizing (B), avoiding knee stockings (D), and cotton socks (E) prevent skin breakdown and promote circulation in PAD. Morning shoe buying (C) is incorrect; shoes should be bought in the afternoon when feet are larger.
Which signs/symptoms would the nurse expect to find in the female client diagnosed with Marfan’s syndrome?
- A. Xerostomia, dry eyes, and complaints of a dry vagina.
- B. A triad of arthritis, conjunctivitis, and urethritis.
- C. Very tall stature and long bones in the hands and feet.
- D. Spinal deformities of the vertebral column and malaise.
Correct Answer: C
Rationale: Marfan’s syndrome causes tall stature and long extremities (C) due to connective tissue defects. Dryness (A) is Sjögren’s, triad (B) is reactive arthritis, and spinal deformities (D) are partial but not primary.
The client diagnosed with a deep vein thrombosis (DVT) is prescribed a heparin drip. The solution is 40,000 units in 500 mL of D5W. The health-care provider ordered the client to receive 1,200 units per hour. At which rate should the nurse set the IV pump?
Correct Answer: 15
Rationale: Heparin concentration: 40,000 units/500 mL = 80 units/mL. Dose: 1,200 units/hr ÷ 80 units/mL = 15 mL/hr. Set pump to 15 mL/hr.
The client with varicose veins asks the nurse, 'What caused me to have these?' Which statement by the nurse would be most appropriate?
- A. You have incompetent valves in your legs.'
- B. Your legs have decreased oxygen to the muscle.'
- C. There is an obstruction in the saphenous vein.'
- D. Your blood is thick and can’t circulate properly.'
Correct Answer: A
Rationale: Varicose veins result from incompetent venous valves (A), causing pooling. Low oxygen (B) is arterial, obstruction (C) is not typical, and thick blood (D) is incorrect.