Nokea
Which client behavior would be a causative factor for developing Buerger's disease (thromboangiitis obliterans)?
- A. Drinking alcohol daily.
- B. Eating a high-fat diet.
- C. Chewing tobacco.
- D. Inhaling gasoline fumes.
Correct Answer: C
Rationale: Buerger’s disease is strongly linked to tobacco use, including chewing tobacco (C), which causes vascular inflammation. Alcohol (A), high-fat diet (B), and gasoline fumes (D) are not primary causes.
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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.
The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?
- A. Administer intravenous antibiotics.
- B. Apply warm moist packs every two (2) hours.
- C. Elevate the right foot on two (2) pillows.
- D. Teach the client about skin and foot care.
Correct Answer: A
Rationale: Cellulitis requires immediate IV antibiotics (A) to treat infection, especially in diabetes. Warm packs (B), elevation (C), and teaching (D) follow to support healing and prevention.
Which assessment data would warrant immediate intervention by the nurse?
- A. The client diagnosed with DVT who complains of pain on inspiration.
- B. The immobile client who has refused to turn for the last three (3) hours.
- C. The client who had an open cholecystectomy who refuses to breathe deeply.
- D. The client who has had an inguinal hernia repair who must void before discharge.
Correct Answer: A
Rationale: Pain on inspiration in DVT (A) suggests pulmonary embolism, requiring immediate action. Immobility (B), shallow breathing (C), and voiding (D) are less urgent.
Which intervention should the nurse include in the plan of care for a client with an arterial ulcer?
- A. Apply a dry, sterile dressing daily.
- B. Elevate the affected leg above heart level.
- C. Encourage ambulation for 30 minutes daily.
- D. Keep the ulcer moist with a hydrogel dressing.
Correct Answer: D
Rationale: Arterial ulcers require a moist wound environment to promote healing, as dry dressings can adhere to the wound and impair tissue regeneration.
Which electrolyte imbalance should the nurse monitor in a client with arrhythmias?
- A. Calcium
- B. Potassium
- C. Sodium
- D. Magnesium
Correct Answer: B
Rationale: Potassium imbalances can trigger or worsen arrhythmias by affecting cardiac cell membrane potential.