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Which intervention should the nurse prioritize for a client with heart failure experiencing shortness of breath?
- A. Administer oxygen as prescribed.
- B. Place the client in a supine position.
- C. Encourage deep breathing exercises.
- D. Restrict all fluid intake.
Correct Answer: A
Rationale: Administering oxygen improves oxygenation in clients with shortness of breath due to heart failure.
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The nurse identifies the concept of clotting for a client diagnosed with a deep vein thrombosis. Which clinical manifestations support the diagnosis?
- A. Brown-purple discoloration on the calf.
- B. Bright red skin on the lower legs.
- C. Swelling in the calf, warmth, and tenderness.
- D. Pain after walking for short distances that resolve with rest.
Correct Answer: C
Rationale: Swelling, warmth, and tenderness (C) are classic DVT signs. Brown-purple (A) is venous insufficiency, red skin (B) is nonspecific, and pain with walking (D) is arterial.
Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours postoperative abdominal aortic aneurysm repair?
- A. Absent bilateral pedal pulses.
- B. Complaints of pain at the site of the incision.
- C. Distended, tender abdomen.
- D. An elevated temperature of 100°F.
Correct Answer: A
Rationale: Absent pedal pulses (A) suggest graft occlusion, a surgical emergency. Incisional pain (B), distension (C), and low-grade fever (D) are expected or less urgent.
The nurse has just received the a.m. shift report. Which client would the nurse assess first?
- A. The client with a venous stasis ulcer who is complaining of pain.
- B. The client with varicose veins who has dull, aching muscle cramps.
- C. The client with arterial occlusive disease who cannot move the foot.
- D. The client with deep vein thrombosis who has a positive Homans’ sign.
Correct Answer: C
Rationale: Inability to move the foot in arterial disease (C) suggests acute ischemia, a priority. Ulcer pain (A), cramps (B), and Homans’ sign (D) are less urgent.
Which instruction should the nurse provide to a client with a new implantable cardioverter-defibrillator (ICD)?
- A. Avoid strong magnetic fields.
- B. Carry heavy bags on the affected side.
- C. Resume contact sports in 2 weeks.
- D. Ignore any shocks you feel.
Correct Answer: A
Rationale: Strong magnetic fields can interfere with ICD function, so clients should avoid them.
The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?
- A. I have stomach pain every time I eat a big, heavy meal.'
- B. I don’t have any abdominal pain or any type of problems.'
- C. I have periodic episodes of constipation and then diarrhea.'
- D. I belch a lot, especially when I lie down after eating.'
Correct Answer: B
Rationale: Small AAAs are often asymptomatic (B). Postprandial pain (A), bowel changes (C), and belching (D) suggest GI issues, not AAA.