Nokea
Which complication should the nurse monitor for in a client with pericarditis?
- A. Cardiac tamponade
- B. Pneumonia
- C. Renal failure
- D. Seizures
Correct Answer: A
Rationale: Cardiac tamponade is a serious complication of pericarditis, where fluid accumulation compresses the heart.
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Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease?
- A. An anticoagulant medication.
- B. An antihypertensive medication.
- C. An antiplatelet medication.
- D. A muscle relaxant.
Correct Answer: C
Rationale: Antiplatelet medications (e.g., aspirin, clopidogrel) (C) prevent clot formation in PAD. Anticoagulants (A) are for DVT, antihypertensives (B) for BP, and muscle relaxants (D) are irrelevant.
When assessing the client's lower leg, which findings characteristic of venous stasis ulcers is the nurse most likely to find? Select all that apply.
- A. Purulent drainage from lesions
- B. Blanched patches around open areas
- C. Dark brown, dry, and crusty skin
- D. Fluid-filled blisters
- E. Edema in the lower legs
- F. Fine red rash below the knee
Correct Answer: C,E
Rationale: Venous stasis ulcers are typically characterized by dark brown, dry, crusty skin due to hemosiderin deposition and edema in the lower legs due to venous insufficiency.
Which diagnostic test would the nurse expect to be ordered for a client suspected of having an arterial disorder?
- A. Ankle-brachial index (ABI)
- B. Venous duplex ultrasound
- C. D-dimer blood test
- D. Complete blood count (CBC)
Correct Answer: A
Rationale: The ankle-brachial index (ABI) is a non-invasive test that compares blood pressure in the ankle and arm to diagnose peripheral artery disease.
The client with aortic stenosis asks why they feel tired. What is the best response?
- A. Your heart is not pumping enough blood.
- B. Your lungs are retaining fluid.
- C. Your blood pressure is too high.
- D. Your heart rate is too slow.
Correct Answer: A
Rationale: Aortic stenosis restricts blood flow from the heart, reducing cardiac output and causing fatigue.
The male client is diagnosed with Guillain-Barré (GB) syndrome and is in the intensive care unit on a ventilator. Which cardiovascular rationale explains implementing passive range-of-motion (ROM) exercises?
- A. Passive ROM exercises will prevent contractures from developing.
- B. The client will feel better if he is able to exercise and stretch his muscles.
- C. ROM exercises will help alleviate the pain associated with GB syndrome.
- D. They help to prevent DVTs by movement of the blood through the veins.
Correct Answer: D
Rationale: Passive ROM (D) promotes venous return, preventing DVT in immobile GB patients. Contractures (A) are musculoskeletal, feeling better (B) is subjective, and pain relief (C) is not primary.