Nokea
Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Frequent nosebleeds
- C. Upper extremity hypotension
- D. Increased intracranial pressure
Correct Answer: A
Rationale: Coarctation causes weak or absent femoral pulses.
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The nurse notes that sediment is present in the urine.
- A. Which of the following actions should the nurse take to obtain a sterile urine specimen?
- B. Disconnect the catheter from the collection tubing.
- C. Obtain the specimen from the retention port.
- D. Use the balloon port to obtain the sterile specimen.
- E. Unclamp the collection port below the bag
Correct Answer: B
Rationale: Retention ports allow sterile specimen collection.
Select the 3 statements the nurse should include in the teaching.
- A. Notify your provider if you experience vomiting or diarrhea.
- B. Limit alcohol intake to no more than one drink per day
- C. You should eat foods that are low in fat.
- D. You can drink beverages that contain caffeine.
- E. You should eat foods highs in protein.
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. A is important as vomiting and diarrhea can lead to dehydration. B is crucial for liver health and overall well-being. C is essential for heart health and maintaining a healthy weight. The other choices are incorrect. D can worsen symptoms and interfere with medication. E may not be suitable for certain health conditions and can lead to weight gain. No information is provided for options F and G.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should not use my affected hand for 4 to 6 weeks.
- B. I will need to keep my hand elevated above my heart for several days.
- C. I should expect numbness and tingling in my hand.
- D. I can apply heat for the first 24 hours to minimize the pain in my hand.
Correct Answer: B
Rationale: Elevation reduces swelling postoperatively.
The nurse should first address the client's.... followed by the client's....
- A. lung, sounds
- B. pain level
- C. bowel sounds
- D. blood glucose level
- E. blood pressure
- F. temperature
Correct Answer: E,F
Rationale: The correct answer is E,F. Firstly, addressing the client's blood pressure (E) is crucial as it assesses cardiovascular health and can indicate potential immediate risks. Secondly, addressing the client's temperature (F) is important as it can indicate infection or other health issues. Choices A, B, C, and D are not the priority as they do not directly relate to immediate cardiovascular or infection risks like blood pressure and temperature do.
Which of the following actions should the nurse take?
- A. Use the palpatory method to determine blood pressure
- B. Place the arm above the level of the client's heart.
- C. Apply the largest cuff available.
- D. Deflate the cuff quickly.
Correct Answer: A
Rationale: The palpatory method can help obtain a more accurate reading when sounds are difficult to auscultate.