Nokea
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.
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The client is at risk for a myocardial infarction due to decreased tissue perfusion as a result of atherosclerosis. Which instructions can the nurse provide the client to reduce the risk?
- A. Teach the client to control the blood pressure to less than 140/90.
- B. Instruct the client to exercise 30 minutes a day three (3) times a week.
- C. Demonstrate how to take the blood pressure using a battery-operated cuff.
- D. Inform the client to limit fat intake and which foods have a higher fat content.
Correct Answer: A,B,D
Rationale: Controlling BP <140/90 (A), exercising 30 min 3×/week (B), and limiting fat (D) reduce MI risk. BP cuff use (C) is monitoring, not prevention.
The nurse is assessing a client with endocarditis. Which finding is most concerning?
- A. Fever of 102°F
- B. Mild fatigue
- C. Heart rate of 90 beats per minute
- D. Blood pressure of 130/85 mmHg
Correct Answer: A
Rationale: Fever is a hallmark of endocarditis and may indicate ongoing infection, requiring prompt attention.
The client presents to the outpatient clinic complaining of calf pain. The client reports returning from an airplane trip the previous day. Which should the nurse assess first?
- A. The nurse should auscultate the lung fields and heart sounds.
- B. The nurse should determine the length of the airplane trip.
- C. The nurse should determine if the client has had chest pain.
- D. The nurse should measure the calf and palpate the calf for warmth.
Correct Answer: C
Rationale: Calf pain post-flight suggests DVT; assessing for chest pain (C) rules out pulmonary embolism, a priority. Lung/heart sounds (A), trip length (B), and calf exam (D) follow.
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 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.