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Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours postoperative abdominal aortic aneurysm repair?
- A. Absent bilateral pedal pulses.
- B. Complaints of pain at the site of the incision.
- C. Distended, tender abdomen.
- D. An elevated temperature of 100°F.
Correct Answer: A
Rationale: Absent pedal pulses (A) suggest graft occlusion, a surgical emergency. Incisional pain (B), distension (C), and low-grade fever (D) are expected or less urgent.
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The nurse has just received the a.m. shift report. Which client would the nurse assess first?
- A. The client with a venous stasis ulcer who is complaining of pain.
- B. The client with varicose veins who has dull, aching muscle cramps.
- C. The client with arterial occlusive disease who cannot move the foot.
- D. The client with deep vein thrombosis who has a positive Homans’ sign.
Correct Answer: C
Rationale: Inability to move the foot in arterial disease (C) suggests acute ischemia, a priority. Ulcer pain (A), cramps (B), and Homans’ sign (D) are less urgent.
Which instruction should the nurse provide to a client with hypertrophic cardiomyopathy?
- A. Engage in competitive sports.
- B. Avoid dehydration.
- C. Take ibuprofen for chest pain.
- D. Limit sleep to 6 hours nightly.
Correct Answer: B
Rationale: Dehydration can exacerbate symptoms in hypertrophic cardiomyopathy by reducing preload.
The client with pericarditis is prescribed ibuprofen. What is the primary purpose of this medication?
- A. Reduce fever
- B. Relieve inflammation
- C. Prevent blood clots
- D. Lower blood pressure
Correct Answer: B
Rationale: Ibuprofen reduces pericardial inflammation, alleviating pain and swelling.
Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency?
- A. Decreased pedal pulses.
- B. Cool skin temperature.
- C. Intermittent claudication.
- D. Brown discolored skin.
Correct Answer: D
Rationale: Brown discoloration (D) results from hemosiderin deposits in venous insufficiency. Decreased pulses (A) and claudication (C) are arterial, and cool skin (B) is not typical (skin is often warm).
The client is at risk for a myocardial infarction due to decreased tissue perfusion as a result of atherosclerosis. Which instructions can the nurse provide the client to reduce the risk?
- A. Teach the client to control the blood pressure to less than 140/90.
- B. Instruct the client to exercise 30 minutes a day three (3) times a week.
- C. Demonstrate how to take the blood pressure using a battery-operated cuff.
- D. Inform the client to limit fat intake and which foods have a higher fat content.
Correct Answer: A,B,D
Rationale: Controlling BP <140/90 (A), exercising 30 min 3×/week (B), and limiting fat (D) reduce MI risk. BP cuff use (C) is monitoring, not prevention.