Nokea
Which nursing action is most helpful in promoting circulation in a client with chronic venous insufficiency?
- A. Limit intake of chips and pretzels.
- B. Encourage mountain biking.
- C. Elevate lower extremities.
- D. Restrict fluid intake to water.
Correct Answer: C
Rationale: Elevating lower extremities reduces venous pressure and promotes blood return, directly improving circulation in chronic venous insufficiency.
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While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?
- A. Appearance of the skin on the client's legs.
- B. Altered posture and balance during ambulation.
- C. Presence of bilateral femoral pulses.
- D. Signs of old and new ecchymosis.
Correct Answer: A
Rationale: Assessing skin appearance for signs of neuropathy supports hair loss as a diabetes complication.
A client is admitted with heart failure (HF) and left ventricular hypertrophy. Which intervention is most likely to avert development of cardiomegaly and improve myocardial contractility?
- A. Teach about compliance to reduce blood pressure.
- B. Provide rest periods and portable oxygen.
- C. Maintain continuous monitoring of heart rate and rhythm.
- D. Administer nitroglycerin daily.
Correct Answer: A
Rationale: Reducing blood pressure decreases cardiac workload, preventing cardiomegaly and improving contractility.
The healthcare provider prescribes cefazolin 800 mg IM every six hours. The available vial is labeled, 'Cefazolin 1 gram,' and the instructions for reconstitution state, For IM use add 2.5 mL sterile water for Injection to provide a total volume of 3.0 mL. After reconstitution, the solution contains how many mg/mL? Enter numeric value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 333
Rationale: One gram (1000 mg) reconstituted in 3.0 mL yields a concentration of 1000 mg / 3 mL = 333.33 mg/mL, rounded to 333 mg/mL.
A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
- A. Encourage active range of motion exercises.
- B. Assist with ambulation in the hallway.
- C. Provide a bedside commode for toileting.
- D. Teach to sleep in a side lying position.
Correct Answer: C
Rationale: A bedside commode minimizes physical exertion, reducing cardiac workload in unstable angina.
A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?
- A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction).
- B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L).
- C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).
- D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);
Correct Answer: C
Rationale: A decrease in BUN indicates improved renal perfusion, a therapeutic outcome of increased IV fluids. Increased hematocrit suggests fluid volume deficit, increased blood glucose is undesirable, and amylase decrease is not directly related to fluid increase.