Nokea
Which of the following assessment findings would be expected in a client with venous thromboembolism in the lower extremity? Select all that apply.
- A. Pain
- B. Swelling
- C. Paralysis
- D. Pulse deficit
- E. Dependent rubor
Correct Answer: A,B
Rationale: Pain is common due to inflammation and clot obstruction in venous thromboembolism (VTE). Swelling occurs due to venous obstruction and fluid accumulation. C: Incorrect - Paralysis is not typical in VTE; it may suggest a neurological issue. D: Incorrect - Pulse deficit is associated with arterial issues, not venous. E: Incorrect - Dependent rubor is characteristic of arterial insufficiency, not VTE.
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The nurse is caring for a client recovering from myocardial infarction who is presenting with a heart rate of 110 beats per minute, a blood pressure of 86/58 mmHg, crackles, shortness of breath, dusky skin, and jugular vein distention. Which action should the nurse recognize as the highest priority?
- A. Administer medications to increase stroke volume.
- B. Provide analgesics.
- C. Obtain a STAT electrocardiogram and troponins.
- D. Administer fluid replacement to increase blood pressure.
Correct Answer: D
Rationale: These findings suggest cardiogenic shock with pulmonary edema. Fluid replacement may be needed, but cautiously, to optimize preload.
The nurse is assessing a client with clinical manifestations of right ventricular heart failure (HF). Which of the following statements by the client would be consistent with this diagnosis?
- A. I notice that my feet are always swollen.
- B. I can't seem to get rid of this wet cough.
- C. I develop shortness of breath after I walk a few feet.
- D. My legs start to burn if I walk long distances.
Correct Answer: A
Rationale: Right ventricular heart failure causes systemic venous congestion, leading to peripheral edema, such as swollen feet.
The nurse observes the following tracing on the telemetry monitor. The nurse should take which initial action? See the image below.
- A. Assess the client's level of consciousness
- B. Prepare the client for immediate defibrillation
- C. Administer a dose of intravenous epinephrine
- D. Evaluate the client's cardiac lead placement
Correct Answer: B
Rationale: A life-threatening rhythm like ventricular fibrillation requires immediate defibrillation to restore normal rhythm.
The nurse is caring for a client with the following tracing on the electrocardiogram. When reviewing the client's medical history, which condition could be causing this dysrhythmia? See the image below.
- A. Graves' disease
- B. Increased intracranial pressure
- C. Severe hypothermia
- D. Myxedema coma
Correct Answer: C
Rationale: Severe hypothermia can cause bradycardia or ventricular arrhythmias, such as Osborne waves, on ECG.
The nurse cares for a client with suspected congestive heart failure (CHF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis?
- A. Basic metabolic panel (BMP)
- B. B-type natriuretic peptide (BNP)
- C. Complete Metabolic Profile (CMP)
- D. C-Reactive Protein (CRP)
Correct Answer: B
Rationale: BNP is a specific marker for heart failure, elevated due to ventricular strain.