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Which of the following should the nurse include in the teaching plan for a client with arterial insufficiency to the feet that is being managed conservatively?
- A. Daily lubrication of the feet.
- B. Soaking the feet in warm water.
- C. Applying antiembolism stockings.
- D. Wearing firm, supportive leather shoes.
Correct Answer: A
Rationale: Daily lubrication prevents skin breakdown in arterial insufficiency, improving circulation.
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The nurse is observing a student nurse administer eyedrops, as shown in the figure. What should the nurse instruct the student to do?
- A. Move the dropper to the inner canthus.
- B. Have the client raise her eyebrows.
- C. Administer the drops in the center of the lower lid.
- D. Have the client squeeze both eyes after administering the drops.
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client's eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.
A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action?
- A. A low, grade 1 intensity mitral regurgitation murmur.
- B. SpO2 is 94% on 2 liters of oxygen via nasal cannula.
- C. The client has become more somnolent.
- D. Urine output has decreased from 60 mL/hour to 40 mL over the last hour.
Correct Answer: C
Rationale: Increased somnolence may indicate neurological complications (e.g., stroke) post-valvuloplasty, requiring immediate action. Other findings are less urgent.
Which of the following indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands his care plan?
- A. The client promises to do pursed-lip breathing at home.
- B. The client states actions to reduce pain.
- C. The client says that he will use oxygen via a nasal cannula at 5 L/minute.
- D. The client agrees to call the physician if dyspnea on exertion increases.
Correct Answer: D
Rationale: Calling the physician for increased dyspnea on exertion shows understanding of when to seek help, a key part of COPD management. Pursed-lip breathing is helpful but less specific. Pain is not a primary COPD issue. High-flow oxygen (5 L/min) may suppress respiratory drive.
A nurse notes that a client has kyphosis and generalized muscle atrophy. Which of the following problems is a priority when the nurse develops a nursing plan of care?
- A. Infection.
- B. Confusion.
- C. Ineffective coughing and deep breathing.
- D. Difficulty chewing solid foods.
Correct Answer: C
Rationale: Kyphosis and muscle atrophy impair chest expansion and cough effectiveness, increasing pneumonia complications. Ineffective coughing and deep breathing is the priority to clear secretions and prevent worsening infection. Infection is already present. Confusion and chewing difficulties are less immediate concerns.
What is the earliest clinical manifestation in a client with acute disseminated intravascular coagulation (DIC)?
- A. Severe shortness of breath.
- B. Bleeding without history or cause.
- C. Orthopnea.
- D. Hematuria.
Correct Answer: B
Rationale: DIC causes widespread clotting and bleeding due to consumption of clotting factors and platelets. The earliest manifestation is often unexplained bleeding, such as petechiae or oozing from venipuncture sites. Shortness of breath, orthopnea, and hematuria are later or less specific signs.