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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.
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The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse?
- A. The telemetry reads normal sinus rhythm.
- B. The client has a weight gain of 2 kg within 1 to 2 days.
- C. The client's blood pressure is 148/92.
- D. The client's serum potassium level is 4.5 mEq.
Correct Answer: B
Rationale: Weight gain of 2 kg in 1–2 days (B) indicates fluid retention, a serious issue in hypertension requiring intervention. Normal sinus rhythm (A), BP 148/92 (C), and K+ 4.5 (D) are not urgent.
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 HCP prescribes an HMG-CoA reductase inhibitor (statin) medication to a client with CAD. Which should the nurse teach the client about this medication?
- A. Take this medication on an empty stomach.
- B. This medication should be taken in the evening.
- C. Do not be concerned if muscle pain occurs.
- D. Check your cholesterol level daily.
Correct Answer: B
Rationale: Statins are most effective in the evening (B) due to cholesterol synthesis peaking at night. Food (A) enhances absorption, muscle pain (C) requires reporting, and daily checks (D) are unnecessary.
When the nurse is planning the client's postoperative care, which action is the highest priority?
- A. Providing the client with protein-rich foods
- B. Ambulating the client frequently
- C. Monitoring for wound infection
- D. Assessing for frequent leg cramping
Correct Answer: C
Rationale: Monitoring for wound infection is critical post-surgery to prevent complications and ensure healing.
The nurse is teaching a client with pericarditis about activity restrictions. Which instruction is most appropriate?
- A. Resume normal activity immediately.
- B. Rest and avoid strenuous activity.
- C. Engage in high-intensity exercise.
- D. Lift heavy objects to build strength.
Correct Answer: B
Rationale: Rest prevents exacerbation of pericardial inflammation and promotes healing.