Nokea
Which assessment data would warrant immediate intervention in the client diagnosed with arterial occlusive disease?
- A. The client has 2+ pedal pulses.
- B. The client is able to move the toes.
- C. The client has numbness and tingling.
- D. The client’s feet are red when standing.
Correct Answer: C
Rationale: Numbness and tingling (C) suggest worsening ischemia or nerve compression, requiring immediate intervention. 2+ pulses (A) and toe movement (B) are normal, and red feet (D) may indicate dependent rubor, less urgent.
You may also like to solve these questions
The nurse is caring for the client with chronic venous insufficiency. Which statement indicates the client understands the discharge teaching?
- A. I shouldn’t cross my legs for more than 15 minutes.'
- B. I need to elevate the foot of my bed while sleeping.'
- C. I should take a baby aspirin every day with food.'
- D. I should increase my fluid intake to 3,000 mL a day.'
Correct Answer: B
Rationale: Elevating the bed (B) reduces edema in venous insufficiency. Crossing legs (A) is discouraged entirely, aspirin (C) is for arterial issues, and 3,000 mL (D) risks fluid overload.
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.
Which medication side effect should the nurse monitor for in a client taking an ACE inhibitor?
- A. Dry cough
- B. Weight gain
- C. Increased thirst
- D. Muscle cramps
Correct Answer: A
Rationale: ACE inhibitors commonly cause a dry cough due to increased bradykinin levels.
When offered the pain medication, the client says to the nurse, 'If that's Motrin, I don't want it. It makes me sick to my stomach.' What is the most appropriate nursing action at this time?
- A. Tell the client that the drug is ibuprofen.
- B. Explain that the prescribed medication must be taken.
- C. Advise the client to take the drug with plenty of water.
- D. Report the information to the charge nurse.
Correct Answer: D
Rationale: Reporting the client's adverse reaction to the charge nurse ensures proper communication and potential adjustment of the medication plan.
The client with hypertension reports dizziness when standing. What should the nurse assess first?
- A. Blood glucose level
- B. Orthostatic blood pressure
- C. Urine output
- D. Respiratory rate
Correct Answer: B
Rationale: Dizziness when standing suggests orthostatic hypotension, which should be confirmed by measuring blood pressure in lying, sitting, and standing positions.