Nokea
Which teaching point should the nurse include for a client with peripheral artery disease? Select all that apply.
- A. Inspect feet daily for sores or injuries.
- B. Wear tight shoes to support the feet.
- C. Stop smoking to improve blood flow.
- D. Exercise until pain occurs, then rest.
- E. Apply lotion to dry skin on legs.
- F. Avoid crossing legs when sitting.
Correct Answer: A,C,D,E,F
Rationale: Inspecting feet, stopping smoking, exercising with rest, applying lotion, and avoiding leg crossing promote circulation and prevent complications in peripheral artery disease.
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Which intervention should the nurse include in the plan of care for a client with pericarditis? Select all that apply.
- A. Monitor for signs of cardiac tamponade.
- B. Administer anti-inflammatory medications.
- C. Encourage deep breathing exercises.
- D. Elevate the head of the bed.
- E. Restrict all physical activity.
- F. Check vital signs every 8 hours.
Correct Answer: A,B,D,E
Rationale: Monitoring for tamponade, administering anti-inflammatories, elevating the bed, and restricting activity manage pericarditis effectively.
The client with varicose veins asks the nurse, 'What caused me to have these?' Which statement by the nurse would be most appropriate?
- A. You have incompetent valves in your legs.'
- B. Your legs have decreased oxygen to the muscle.'
- C. There is an obstruction in the saphenous vein.'
- D. Your blood is thick and can’t circulate properly.'
Correct Answer: A
Rationale: Varicose veins result from incompetent venous valves (A), causing pooling. Low oxygen (B) is arterial, obstruction (C) is not typical, and thick blood (D) is incorrect.
The client with atrial fibrillation is prescribed warfarin. Which laboratory value should the nurse monitor?
- A. Platelet count
- B. International normalized ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Red blood cell count
Correct Answer: B
Rationale: Warfarin's anticoagulant effect is monitored using INR to ensure therapeutic levels and prevent bleeding or clotting.
Which assessment data would warrant immediate intervention by the nurse?
- A. The client diagnosed with DVT who complains of pain on inspiration.
- B. The immobile client who has refused to turn for the last three (3) hours.
- C. The client who had an open cholecystectomy who refuses to breathe deeply.
- D. The client who has had an inguinal hernia repair who must void before discharge.
Correct Answer: A
Rationale: Pain on inspiration in DVT (A) suggests pulmonary embolism, requiring immediate action. Immobility (B), shallow breathing (C), and voiding (D) are less urgent.
Which of the following nursing interventions is most helpful in promoting venous circulation?
- A. Offer the client an analgesic for pain.
- B. Apply elastic compression stockings.
- C. Encourage complete bedrest for 48 hours.
- D. Teach the client to sit with legs dependent.
Correct Answer: B
Rationale: Elastic compression stockings promote venous return by applying graduated pressure, reducing edema and improving circulation.