Nokea
Which response by the nurse about blood circulation is most appropriate?
- A. The arteries begin to function as veins.
- B. New veins grow to replace the ones that were removed.
- C. Other veins take over the work of those removed.
- D. The healthy vein ends are attached to other veins.
Correct Answer: C
Rationale: After vein stripping, other superficial and deep veins compensate for the removed veins, maintaining circulation.
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Which actions should the surgical scrub nurse take to prevent personally developing a DVT?
- A. Keep the legs in a dependent position and stand as still as possible.
- B. Flex the leg muscles and change the leg positions frequently.
- C. Wear white socks and shoes that have an elevated heel.
- D. Ask the surgeon to allow the nurse to take a break midway through each surgery.
Correct Answer: B
Rationale: Flexing muscles and changing positions (B) promote venous return, preventing DVT. Dependent position (A) increases risk, socks/heels (C) are irrelevant, and breaks (D) are impractical.
Which client problem would be priority in a client diagnosed with arterial occlusive disease who is admitted to the hospital with a foot ulcer?
- A. Impaired skin integrity.
- B. Activity intolerance.
- C. Ineffective health maintenance.
- D. Risk for peripheral neuropathy.
Correct Answer: A
Rationale: A foot ulcer in PAD indicates impaired skin integrity (A), the priority due to infection risk. Activity intolerance (B), health maintenance (C), and neuropathy (D) are secondary.
Which complication of anticoagulant therapy should the nurse teach the client to report to the health-care provider?
- A. Gastric upset.
- B. Bleeding from any site.
- C. Constipation.
- D. Myocardial infarction.
Correct Answer: B
Rationale: Bleeding (B) is a serious anticoagulant complication, requiring HCP notification. Gastric upset (A) and constipation (C) are minor, and MI (D) is unrelated.
The client diagnosed with a deep vein thrombosis is prescribed heparin via continuous infusion. The client's laboratory data are: PT 12.2 aPTT 48 Control 1.4 Control 32 INR 1 Based on the laboratory results, which intervention should the nurse implement?
- A. Request a change of medication to a subcutaneous anticoagulant.
- B. Administer AquaMephyton (vitamin K) IM.
- C. Have the dietary department remove all green, leafy vegetables from the trays.
- D. Administer the IV as ordered.
Correct Answer: D
Rationale: aPTT 48 (therapeutic 1.5–2× control 32 = 48–64) is within range; continue heparin as ordered (D). Subcutaneous (A) is inappropriate, vitamin K (B) reverses heparin, and diet (C) is for warfarin.
The client is being admitted with Coumadin (warfarin, an anticoagulant) toxicity. Which laboratory data should the nurse monitor?
- A. Blood urea nitrogen (BUN) levels.
- B. Bilirubin levels.
- C. International normalized ratio (INR).
- D. Partial thromboplastin time (PTT).
Correct Answer: C
Rationale: Warfarin toxicity is monitored via INR (C), which reflects bleeding risk. BUN (A) assesses kidneys, bilirubin (B) liver, and PTT (D) is for heparin.