Nokea
Which risk factor revealed in the client's health history is most closely related to the development of varicose veins?
- A. The client's mother also has varicose veins.
- B. The client was a track athlete in high school.
- C. The client is a 50-year-old corporate executive.
- D. The client smokes one pack of cigarettes daily.
Correct Answer: A
Rationale: Varicose veins have a strong genetic component, so a family history, such as the client's mother having varicose veins, is a significant risk factor.
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The client is receiving prophylactic low molecular weight heparin. There are no PT/PTT or INR results on the client's chart since admission three (3) days ago. Which action should the nurse implement?
- A. Administer the medication as ordered.
- B. Notify the health-care provider immediately.
- C. Obtain the PT/PTT and INR prior to administering the medication.
- D. Hold the medication until the HCP makes rounds.
Correct Answer: A
Rationale: LMWH (e.g., enoxaparin) does not require PT/PTT/INR monitoring (A); it’s administered as ordered. Notifying HCP (B), obtaining labs (C), or holding (D) are unnecessary.
The nurse is teaching a client about heart failure medications. Which statement about furosemide (Lasix) is accurate?
- A. It strengthens your heart muscle.
- B. It lowers your blood pressure.
- C. It helps remove excess fluid.
- D. It prevents irregular heartbeats.
Correct Answer: C
Rationale: Furosemide is a loop diuretic that promotes fluid excretion, reducing preload in heart failure.
The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first?
- A. Complete a neurovascular assessment.
- B. Use the Doppler device.
- C. Instruct the client to hang the feet off the side of the bed.
- D. Wrap the legs in a blanket.
Correct Answer: B
Rationale: Absent pedal pulse in PAD requires Doppler use (B) to confirm blood flow. Neurovascular assessment (A) follows, dependent position (C) worsens ischemia, and blankets (D) are irrelevant.
The client with peripheral artery disease asks why they need to walk daily. What is the best response?
- A. It strengthens your leg muscles.
- B. It promotes collateral circulation.
- C. It reduces swelling in your legs.
- D. It prevents venous ulcers.
Correct Answer: B
Rationale: Walking stimulates the development of collateral vessels, improving blood flow in peripheral artery disease.
Which should the nurse include in the plan of care for a client diagnosed with venous stasis ulcers? Select all that apply.
- A. Elevate the legs while sitting.
- B. Wear antiembolism compression stockings.
- C. Avoid injury to the lower limbs.
- D. Trim the toenails straight across.
- E. Do not apply moisturizer to the lower legs.
- F. Allow the legs to hang over the bed in a dependent position.
Correct Answer: A,B,C,D
Rationale: Leg elevation (A), compression stockings (B), injury avoidance (C), and straight toenail trimming (D) manage venous ulcers. Moisturizer (E) is beneficial, and dependent position (F) worsens edema.