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During a routine clinic visit, a nurse is assessing a 48-year-old client with a history of smoking. The client, who exercises regularly, reports calf pain during exercise that disappears at rest. Which of the following findings requires further evaluation?
- A. Heart rate of 57 bpm.
- B. SpO2 of 94% on room air.
- C. Blood pressure of 134/82.
- D. Ankle-brachial index of 0.65.
Correct Answer: D
Rationale: An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client experiencing intermittent claudication, indicating compromised blood flow to the lower extremities during exercise. This finding requires further evaluation to assess the severity of arterial insufficiency and determine appropriate interventions.
Choice A (Heart rate of 57 bpm) is within the normal range for an adult at rest and indicates good cardiovascular fitness. Choice B (SpO2 of 94% on room air) is slightly lower than the normal range but is generally acceptable in a healthy individual. Choice C (Blood pressure of 134/82) falls within the normal range and does not raise immediate concerns in this context.
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Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client's right radial pulse. Which action should the nurse take first?
- A. Notify the healthcare provider of the finding immediately.
- B. Complete a neurovascular assessment of the right hand.
- C. Elevate the client's right hand on one or two pillows.
- D. Measure the client's blood pressure and apical pulse rate.
Correct Answer: B
Rationale: Completing a neurovascular assessment of the right hand is the priority in this situation. This assessment will help determine the circulation, sensation, and movement of the affected limb, ensuring there are no complications like compartment syndrome or impaired perfusion. Notifying the healthcare provider immediately (Choice A) might be necessary but should come after assessing the client's neurovascular status. Elevating the client's right hand (Choice C) can be helpful in some cases but should not precede a neurovascular assessment. Measuring the client's blood pressure and apical pulse rate (Choice D) is important but not the priority when assessing a potential vascular compromise in the limb.
A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?
- A. Distended, hard, and rigid abdomen
- B. Clay-colored stool
- C. Radiating sharp pain in the right shoulder
- D. Bile-stained emesis
Correct Answer: A
Rationale: The most important finding for the nurse to report to the healthcare provider in a client with cholelithiasis and jaundice due to common bile duct obstruction is a distended, hard, and rigid abdomen. These signs may indicate a possible surgical emergency, such as a complication like gallbladder perforation or peritonitis, which require immediate intervention. Clay-colored stool is associated with obstructive jaundice but does not indicate an acute surgical emergency. Radiating sharp pain in the right shoulder (referred pain from the diaphragm) and bile-stained emesis may also be seen in cholelithiasis but are not as urgent as a distended, hard, and rigid abdomen.
Which of the following is a sign of hypocalcemia?
- A. Hyperactive reflexes.
- B. Depressed reflexes.
- C. Muscle cramps.
- D. Seizures.
Correct Answer: A
Rationale: Hyperactive reflexes are a classic sign of hypocalcemia. Hypocalcemia leads to increased neuromuscular excitability, resulting in hyperactive reflexes. Depressed reflexes (Choice B) are not typically associated with hypocalcemia. Muscle cramps (Choice C) can be seen in hypocalcemia due to muscle irritability but are not a specific sign. Seizures (Choice D) can occur in severe cases of hypocalcemia but are not as common as hyperactive reflexes.
A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following?
- A. I am having fewer aches and pains.
- B. I do not have headaches anymore.
- C. I am able to walk further without leg pain.
- D. My toes are turning grayish black in color.
Correct Answer: C
Rationale: The correct answer is C. Cilostazol improves blood flow to the muscles, which helps alleviate symptoms of intermittent claudication. An improvement in walking distance without leg pain indicates the effectiveness of the medication. Choices A and B are not directly related to the expected outcome of Cilostazol therapy for intermittent claudication. Choice D is concerning for a potential adverse effect and should be reported to the healthcare provider immediately.
When conducting discharge teaching for a client diagnosed with diverticulitis, which diet instruction should the nurse include?
- A. Have small, frequent meals and sit up for at least two hours after meals
- B. Eat a bland diet and avoid spicy foods
- C. Eat a high-fiber diet and increase fluid intake
- D. Eat a soft diet with increased intake of milk and milk products
Correct Answer: C
Rationale: For a client diagnosed with diverticulitis, the nurse should instruct them to eat a high-fiber diet and increase fluid intake. This diet helps in managing diverticulitis by promoting bowel regularity and preventing complications such as diverticular inflammation or infection. Choice A of having small, frequent meals and sitting up for at least two hours after meals may be beneficial for gastroesophageal reflux disease but is not specific to diverticulitis. Choice B of eating a bland diet and avoiding spicy foods is not the preferred recommendation for diverticulitis management. Choice D of eating a soft diet with increased intake of milk and milk products may not provide enough fiber to aid in diverticulitis management, and the increased intake of dairy products may worsen symptoms in some individuals.