Nokea
Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.)
- A. A good abrasive pumice stone will keep my feet soft
- B. I'll always wear shoes if I can buy cheap flip-flops
- C. I need to check my feet daily for sores
- D. Lotion is important to keep my feet smooth and soft
- E. Washing my feet in room-temperature water is best
Correct Answer: C,D,E
Rationale: Good foot care includes checking for sores, using lotion, and washing in room-temperature water to prevent injury. Abrasive pumice stones and flip-flops can cause harm due to decreased sensation in PVD.
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A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?
- A. Administer prescribed pain medication
- B. Assess distal pulses and skin color
- C. Document the findings in the client's chart
- D. Notify the surgeon immediately
Correct Answer: B
Rationale: Assessing distal pulses and skin color is the priority to ensure adequate circulation post-surgery. Severe pain could indicate complications like graft occlusion. Administering pain medication, documenting, or notifying the surgeon are secondary until circulation is confirmed.
A nurse is caring for a client on IV infusion of heparin. What actions does the nurse include in the client's plan? (Select all that apply.)
- A. Assess the client for bleeding
- B. Monitor the daily activated partial thromboplastin time (aPTT) results
- C. Stop the IV if aPTT shows baseline
- D. Use an IV pump for the infusion
- E. Weigh the client daily on the same scale
Correct Answer: A,B,D
Rationale: Assessing for bleeding, monitoring aPTT, and using an IV pump are critical for heparin safety. Stopping the IV at baseline aPTT is incorrect, as therapeutic levels are 1.5-2 times baseline. Weighing is not directly related.
A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Ambulate the client
- B. Apply a warm moist pack
- C. Massage the client's leg
- D. Provide an ice pack
Correct Answer: B
Rationale: Warm moist packs can help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client's legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.
A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would assess the locally primary interview?
- A. Assessing blood pressure in both upper extremities
- B. Auscultating the carotid arteries for any bruits
- C. Classifying capillary refill of 4 seconds as normal
- D. Palpating both carotid arteries at the same time
Correct Answer: D
Rationale: The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding indicates a priority outcome for this client has been met?
- A. Pain rated as 2/10 after medication
- B. Distal pulse on affected extremity 2+/4
- C. Client remains on bedrest as directed
- D. Verifies understanding of procedure
Correct Answer: B
Rationale: Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4 indicates good perfusion, meeting a priority outcome. The other options are important but secondary to circulation.