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Which finding should the nurse report immediately in a client with a deep vein thrombosis (DVT)?
- A. Warm, red skin over the affected area
- B. Mild leg pain
- C. Heart rate of 80 beats per minute
- D. Blood pressure of 130/85 mmHg
Correct Answer: A
Rationale: Warm, red skin over the affected area may indicate worsening DVT or complications like thrombophlebitis, requiring immediate attention.
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Which finding in a client with an arterial disorder indicates a worsening condition?
- A. Cool, pale skin on the affected leg
- B. Mild leg pain at rest
- C. Heart rate of 75 beats per minute
- D. Blood pressure of 125/80 mmHg
Correct Answer: A
Rationale: Cool, pale skin indicates worsening arterial insufficiency, suggesting reduced blood flow to the limb.
The client on the telemetry unit diagnosed with a thromboembolism is complaining of chest pain and anxiety. Which action should the nurse implement first?
- A. Stay with the client and call the Rapid Response Team (RRT).
- B. Assess the client’s vital signs.
- C. Have the unlicensed assistive personnel (UAP) stay with the client.
- D. Check the client’s telemetry reading.
Correct Answer: A
Rationale: Chest pain/anxiety in thromboembolism suggests pulmonary embolism; calling RRT (A) ensures rapid intervention. Vitals (B), UAP (C), and telemetry (D) follow.
The client with heart failure reports fatigue. Which action should the nurse take first?
- A. Encourage bedrest all day.
- B. Assess oxygen saturation.
- C. Administer a diuretic.
- D. Increase fluid intake.
Correct Answer: B
Rationale: Fatigue in heart failure may indicate hypoxemia, so assessing oxygen saturation is the priority.
Which client would be most at risk for developing varicose veins?
- A. A Caucasian female who is a nurse.
- B. An African American male who is a bus driver.
- C. An Asian female with no children.
- D. An elderly male with diabetes.
Correct Answer: A
Rationale: Nurses (A) stand for long periods, increasing varicose vein risk. Bus drivers (B) sit, nulliparity (C) is less risky, and diabetes (D) is not a direct factor.
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.