Nokea
Which discharge instruction should the nurse provide to 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 Berger-Allen exercises (4) times a day.
Correct Answer: A
Rationale: The correct answer is to instruct the client to walk 15 to 20 minutes three times a day. Walking helps improve circulation and reduces the risk of complications following sclerotherapy. Choice B, keeping the legs in the dependent position when sitting, is incorrect as it can increase venous pressure. Choice C, removing compression bandages before going to bed, is incorrect as compression should be maintained as per healthcare provider's instructions. Choice D, performing Berger-Allen exercises four times a day, is incorrect as these exercises may not be specifically recommended post-sclerotherapy.
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Which of the following is a primary factor that affects blood pressure?
- A. Obesity
- B. Age
- C. Stress
- D. Gender
Correct Answer: A
Rationale: Obesity is a primary factor that affects blood pressure. Excess body weight, especially when concentrated around the abdomen, can increase the risk of hypertension (high blood pressure) as it puts extra strain on the heart to pump blood around the body. This can lead to various cardiovascular complications and other health issues. Managing weight through a healthy diet and regular physical activity can help control blood pressure levels. Age, stress, and gender can also influence blood pressure, but obesity has a more direct and significant impact on increasing blood pressure levels compared to the other factors listed.
A patient with chronic renal failure should avoid which of the following?
- A. Potassium
- B. Calcium
- C. Iron
- D. Zinc
Correct Answer: A
Rationale: Patients with chronic renal failure should avoid potassium due to impaired kidney function. The kidneys play a crucial role in regulating potassium levels in the body. In renal failure, the kidneys may not be able to excrete excess potassium effectively, leading to hyperkalemia. Calcium, iron, and zinc are not typically restricted in chronic renal failure unless there are specific individual circumstances, making them incorrect choices.
The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?
- A. Deep tendon reflexes
- B. Arterial blood gases
- C. Skin turgor
- D. Capillary refill time
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes. When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Choices B, C, and D are not directly related to the assessment needed when administering magnesium sulfate in this scenario. Arterial blood gases are not typically assessed specifically for magnesium sulfate administration; skin turgor and capillary refill time are more related to hydration status and perfusion, respectively.
A family came to the emergency department with complaints of food poisoning. Which client should the nurse see first?
- A. 32-year-old with diarrhea for 6 hours
- B. 2-year-old with 1 wet diaper in 24 hours
- C. 40-year-old with abdominal cramping
- D. 10-year-old who is nauseated
Correct Answer: B
Rationale: The correct answer is B because a 2-year-old with reduced urine output (1 wet diaper in 24 hours) is at high risk for dehydration. Dehydration can occur rapidly in young children and can be life-threatening. The nurse should prioritize assessing and managing the dehydration of the 2-year-old. Choices A, C, and D, although they may also require attention, do not present the same level of immediate risk as a dehydrated 2-year-old.
The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?
- A. Second intercostal space, right sternal border
- B. Erb's point
- C. Second intercostal space, left sternal border
- D. Fourth intercostal space, left sternal border
Correct Answer: A
Rationale: The correct anatomical position for auscultating the murmur of aortic stenosis is the second intercostal space, right sternal border. This is where the aortic valve is best auscultated, and the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as the murmur of aortic stenosis is best heard at the second intercostal space on the right side of the sternum.