Nokea
Which nursing diagnosis is most appropriate for a patient with chronic venous insufficiency?
- A. Activity Intolerance.
- B. Body Image, disturbed.
- C. Fluid Volume, deficient.
- D. Skin Integrity, impaired.
Correct Answer: D
Rationale: Chronic venous insufficiency increases the risk of skin breakdown, making impaired skin integrity the most relevant diagnosis.
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Which of the following symptoms is observed in the client with right-sided heart failure?
- A. Dependent pitting edema
- B. Exertional dyspnea
- C. Orthopnea
- D. Hemoptysis
Correct Answer: A
Rationale: Right-sided heart failure leads to fluid retention, causing dependent pitting edema.
What is the condition where the blood vessels that supply blood to the legs and feet become narrowed or blocked, causing pain and difficulty walking?
- A. Peripheral artery disease
- B. Raynaud's disease
- C. Varicose veins
- D. Pulmonary embolism
Correct Answer: A
Rationale: The correct answer is A: Peripheral artery disease (PAD). PAD is characterized by narrowed or blocked blood vessels in the legs, leading to reduced blood flow, causing pain and difficulty walking (claudication). The narrowing is typically due to atherosclerosis. Raynaud's disease (B) involves spasms of small arteries, causing reduced blood flow to fingers and toes, not legs. Varicose veins (C) are enlarged, twisted veins, not arteries. Pulmonary embolism (D) is a blockage in the lungs' arteries, not the legs.
What is a condition where the alveoli are gradually destroyed, leading to shortness of breath and reduced oxygen exchange?
- A. Emphysema
- B. Pulmonary fibrosis
- C. Pulmonary edema
- D. Lung cancer
Correct Answer: A
Rationale: Emphysema is the correct answer. Alveoli destruction in emphysema leads to shortness of breath and reduced oxygen exchange. This condition is primarily caused by smoking and results in irreversible damage to the air sacs in the lungs. Pulmonary fibrosis involves scarring of lung tissue, not alveoli destruction. Pulmonary edema is fluid accumulation in the lungs, disrupting oxygen exchange. Lung cancer is the uncontrolled growth of abnormal cells in the lung, which may not directly lead to alveoli destruction.
This test measures the amount of blood the heart pumps with each beat, often used to assess heart function.
- A. Ejection fraction
- B. Cardiac output
- C. Stroke volume
- D. End-diastolic volume
Correct Answer: A
Rationale: The correct answer is A: Ejection fraction. Ejection fraction is the percentage of blood pumped out of the heart's left ventricle with each contraction. It is a key indicator of heart function and can help diagnose heart conditions such as heart failure. Cardiac output (B) is the total amount of blood pumped by the heart per minute, not the amount pumped with each beat. Stroke volume (C) is the amount of blood pumped by the heart in one contraction, not specifically with each beat. End-diastolic volume (D) is the amount of blood in the ventricle before contraction, not the amount pumped with each beat.
The client on warfarin has an INR of 3.8. What is the most appropriate action by the nurse?
- A. Administer vitamin K.
- B. Hold the next dose of warfarin.
- C. Increase the dose of warfarin.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: The correct answer is A: Administer vitamin K. When a client on warfarin has an INR above the therapeutic range (usually 2-3), like in this case (3.8), administering vitamin K is appropriate to reverse the anticoagulant effects. This helps prevent bleeding complications. Holding the next dose of warfarin (B) may not be sufficient to lower the INR quickly. Increasing the dose of warfarin (C) would further elevate the INR, leading to higher bleeding risk. Notifying the healthcare provider (D) is important, but immediate action with vitamin K is necessary to address the high INR.