Nokea
Which assessment finding would most likely indicate that a client has thrombophlebitis in the leg?
- A. Diminished pedal pulses
- B. Color changes in the extremities when elevated
- C. Red, shiny skin
- D. Coolness and pallor in the leg
Correct Answer: C
Rationale: Red, shiny skin is a common sign of thrombophlebitis due to inflammation and impaired venous return. Diminished pulses, color changes with elevation, or coolness are more indicative of arterial issues.
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When gathering nursing assessment data, which finding will adults with chronic cardiac diseases most frequently, the client is a good treatment.
- A. Barrel-shaped chest
- B. Flushed facial skin
- C. Clubbed fingertips
- D. Chest pain
Correct Answer: C
Rationale: Clubbed fingertips are common in chronic cardiac diseases due to chronic hypoxia.
Which response by the nurse is most appropriate at this time?
- A. What are your concerns?
- B. Why are you so scared?
- C. Your doctor says you are doing just fine.
- D. You need to concentrate on getting well.
Correct Answer: A
Rationale: Asking about concerns encourages the client to express fears, facilitating emotional support and reducing anxiety.
If each tablet of digoxin (Lanoxin) contains 0.25 mg, how much should the nurse administer to the client each day?
- A. 0.5 tablets
- B. 1 tablet
- C. 0.25 tablets
- D. 0.125 tablets
Correct Answer: A
Rationale: For a 0.125 mg dose with 0.25 mg tablets, administer 0.5 tablets (0.125 mg ÷ 0.25 mg = 0.5).
Which laboratory results would the nurse expect to be elevated if the client had a myocardial infarction (MI)?
- A. Isoenzymes and troponin
- B. Sodium and potassium
- C. Red blood cells and platelets
- D. Plasminogen and lactic acid
Correct Answer: A
Rationale: Troponin and cardiac isoenzymes (e.g., CK-MB) are specific markers of myocardial damage in MI.
When a client returns from undergoing a cardiac catheterization, it is most essential for the nurse to:
- A. check peripheral pulses.
- B. maintain NPO.
- C. apply heat to the insertion site.
- D. start range of motion exercises immediately.
Correct Answer: A
Rationale: Checking peripheral pulses post-cardiac catheterization is essential to detect complications like arterial occlusion or hematoma at the insertion site. Maintaining NPO, applying heat, or starting range of motion exercises immediately are not standard priorities.