Nokea
Which client problem would be priority in a client diagnosed with arterial occlusive disease who is admitted to the hospital with a foot ulcer?
- A. Impaired skin integrity.
- B. Activity intolerance.
- C. Ineffective health maintenance.
- D. Risk for peripheral neuropathy.
Correct Answer: A
Rationale: A foot ulcer in PAD indicates impaired skin integrity (A), the priority due to infection risk. Activity intolerance (B), health maintenance (C), and neuropathy (D) are secondary.
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The client prescribed rivaroxaban (Xarelto), an anticoagulant, is complaining of dark, tarry stool. Which should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Ask the client to provide a stool sample.
- C. Ask the client when the rivaroxaban was last taken.
- D. Assess the client for ecchymotic areas and bleeding.
Correct Answer: A
Rationale: Dark, tarry stool suggests GI bleeding; notifying HCP (A) is first for urgent evaluation. Stool sample (B), last dose (C), and bleeding assessment (D) follow.
The nurse is discussing discharge teaching with the client who is three (3) days postoperative abdominal aortic aneurysm repair. Which discharge instructions should the nurse include when teaching the client?
- A. Notify the HCP of any redness or irritation of the incision.
- B. Do not lift anything that weighs more than 20 pounds.
- C. Inform the client there may be pain not relieved with pain medication.
- D. Stress the importance of having daily bowel movements.
Correct Answer: A,B
Rationale: Notifying HCP of redness (A) and limiting lifting to <20 lbs (B) prevent infection and graft stress. Unrelieved pain (C) requires evaluation, and daily BMs (D) are not critical.
Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy?
- A. Walk 15 to 20 minutes three (3) times a day.
- B. Keep the legs in the dependent position when sitting.
- C. Remove compression bandages before going to bed.
- D. Perform Buerger-Allen exercises four (4) times a day.
Correct Answer: A
Rationale: Walking 15–20 minutes 3×/day (A) promotes venous return post-sclerotherapy. Dependent position (B) worsens pooling, bandages (C) stay on, and Buerger-Allen (D) is for arterial disease.
The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins?
- A. Wear low-heeled, comfortable shoes.
- B. Wear clean white cotton socks.
- C. Move the legs back and forth often.
- D. Wear graduated compression hose.
Correct Answer: D
Rationale: Compression hose (D) prevent venous pooling, reducing varicose vein risk. Low heels (A), socks (B), and leg movement (C) help but are less effective.
The nurse is completing a neurovascular assessment on the client with chronic venous insufficiency. What should be included in this assessment? Select all that apply.
- A. Assess for paresthesia.
- B. Assess for pedal pulses.
- C. Assess for paralysis.
- D. Assess for pallor.
- E. Assess for polar (temperature).
Correct Answer: A,B
Rationale: Paresthesia (A) and pedal pulses (B) assess neurovascular status in venous insufficiency. Paralysis (C) and pallor (D) are arterial, and polar/temperature (E) is assessed but not primary.