Question 5051)
Which assessment finding would most likely indicate that a client has thrombophlebitis in the leg?
A. Diminished pedal pulses
B. Color changes in the extremities when elevated
C. Red, shiny skin
D. Coolness and pallor in the leg
Answer: C
Explanation: Red, shiny skin suggests inflammation. Diminished pedal pulses and color changes in the extremities when elevated are indicative of arterial insufficiency, not a clot in the vein. Coolness and pallor do not suggest inflammation; redness and warmth suggest inflammation.
Question 5052)
What should be included in the teaching plan for an adult who has hypertension?
A. Reduce dietary calcium
B. Avoid aerobic exercise
C. Reduce alcohol intake
D. Limit fluid intake.
Answer: C
Explanation: High alcohol intake contributes to increases in blood pressure. Hypertensive clients are usually advised to limit alcohol intake to the equivalent of two glasses of wine or less per day. Dietary sodium should be limited in people with hypertension; however, dietary calcium is not a contributing factor in hypertension. Aerobic exercise is helpful in controlling high blood pressure. It may also contribute to weight reduction, which can help decrease blood pressure. Restriction of fluid intake is a medical order and is not appropriate advice for a nurse to give. Fluid restriction is avoided unless other measures are not successful.
Question 5053)
The nurse is caring for an elderly client who has congestive heart failure and is taking digoxin. The client should be monitored for which of the following signs of toxicity?
A. Disorientation
B. Weight gain
C. Constipation
D. Dyspnea
Answer: A
Explanation: Disorientation and confusion are often the first signs of digitalis toxicity in the elderly. Weight gain and dyspnea are not signs of digoxin toxicity. They might indicate exacerbation of congestive heart failure. Diarrhea, not constipation, is a sign of digoxin toxicity. Constipation could occur if the client has restricted activity.
Question 5054)
The licensed practical nurse (LPN) is assisting the registered nurse (RN) in developing the nursing care plan for an older adult who has congestive heart failure. Which nursing diagnosis is most likely to be included?
A. Deficient fluid volume
B. Impaired verbal communication
C. Chronic pain
D. Activity intolerance
Answer: D
Explanation: Dyspnea and impaired oxygenation of tissues reduce the client’s ability to tolerate exercise. Excess fluid volume, manifested by edema, is much more likely to occur with congestive heart failure (CHF) than deficient fluid volume. Impaired verbal communication would describe dysphasia, which occurs with cerebrovascular accident (CVA), not CHF. Acute pain may occur with CHF when exacerbations occur. Chronic pain does not usually occur with CHF.
Question 5055)
The nurse is caring for a client who is being evaluated for arteriosclerosis obliterans. Which complaint is the client most likely to have?
A. Burning pain in the legs that wakens him or her at night
B. Numbness of the feet and ankles with exercise
C. Leg pain while walking that becomes severe enough to force him or her to stop
D. Increasing warmth and redness of the legs when they are elevated
Answer: C
Explanation: Severe leg pain while walking describes intermittent claudication, which is the most common symptom of arteriosclerosis obliterans. Pain at rest develops in the late stages of the disease. Pain is much more likely than numbness with exercise. Paresthesias (including numbness) do occur, but they are likely at rest. The legs and feet of the client with arteriosclerosis obliterans become cool and pale when elevated because there is not enough blood flow to the extremities.
Question 5056)
An adult is admitted with venous thromboembolism. What treatment should the nurse expect during the acute stage?
A. Application of an elastic stocking
B. Ambulation three times a day
C. Passive range of motion exercises to the legs
D. Use of ice packs to control pain
Answer: A
Explanation: Compression bandages or stockings help prevent edema and promote adequate venous blood flow and are a major element in the treatment of venous thromboembolism. Bed rest is appropriate in the acute stage of venous thromboembolism. Any form of exercise of the legs would increase the risk of pulmonary emboli. Heat is appropriate in the treatment of venous thromboembolism. Ice causes vasoconstriction, which decreases blood flow to the extremities.
Question 5057)
The nurse is observing a client who is learning to perform Buerger-Allen exercises. The nurse knows that the client is performing these exercises correctly when the client is observed doing what?
A. Alternately dorsiflexing and plantar flexing the feet while the legs are elevated
B. Massaging the legs beginning at the feet and moving toward the heart
C. Alternately walking short distances and resting with the legs elevated
D. Elevating the legs, then dangling them, and then lying flat for three minutes in each position
Answer: D
Explanation: In Buerger-Allen exercises, the feet are elevated until they blanch, then dangled until they redden, and then stretched out while the client is lying flat. This promotes arterial circulation to the feet. Dorsiflexing and plantar flexing the feet help to maintain range of motion but are not BuergerAllen exercises. The client with peripheral vascular disease should never massage the legs because of the high risk of dislodging a thrombus if one is present. Walking promotes venous circulation but is not a Buerger-Allen exercise.
Question 5058)
What should be included in foot care for the client who has a peripheral vascular disorder?
A. Soaking the feet for 20 minutes before washing them
B. Walking barefoot only on carpeted floors
C. Applying lotion between the toes to avoid cracking of the skin
D. Avoiding exposure of the legs and feet to the sun
Answer: D
Explanation: Sunburn would damage the already fragile skin, increasing the risk of ulceration and infection. Feet should not be soaked. Soaking leads to maceration, predisposing to skin breakdown or infection. The client with a peripheral vascular disorder should never walk barefoot. Small sharp objects such as pins may not be visible in carpet and could be stepped on. Lotion may be applied to dry areas of the legs and feet but must be avoided between the toes, where the excess moisture the causes maceration. Ingredients in lotion provide a nutrient source for bacteria and fungi, increasing the infection risk if cracks in the skin occur.
Question 5059)
An adult male is being evaluated for possible dysrhythmia and is to be placed on a Holter monitor. What instructions should the nurse give him to ensure that this test provides a comprehensive picture of his cardiac status?
A. Remove the electrodes intermittently for hygiene measures.
B. Exercise frequently while the monitor is in place.
C. Keep a diary of all your activities while being monitored.
D. Refrain from activities that precipitate symptoms.
Answer: C
Explanation: The client should function according to his normal daily schedule unless directed to do otherwise by the physician. Keeping a diary or log of these daily activities is necessary so that it can be correlated with the continuous ECG monitor strip to determine whether the dysrhythmia occurs during a certain activity or at a particular time of day. The Holter monitor is usually worn for only 24 hours, so it is not necessary to change the leads. Activities that precipitate symptoms may be correlated with a dysrhythmia that can be treated, preventing further symptoms from occurring. Therefore, it would be helpful if the client were symptomatic while attached to the Holter monitor.
Question 5060)
An older adult is scheduled for coronary arteriography during a cardiac catheterization. Which nursing intervention will be essential as she recovers from the diagnostic procedure on the hospital unit?
A. Encouraging frequent ambulation to prevent deep vein thrombosis
B. Limiting fluid intake to prevent fluid overload
C. Limiting dietary fiber to prevent diarrhea
D. Assessing the arterial puncture site when taking vital signs
Answer: D
Explanation: Following a cardiac catheterization in which an arterial site is used for access, the puncture or cutdown site should be assessed at least as often as vital signs are monitored. The client is at risk for development of bleeding, hemorrhage, hematoma formation, and arterial insufficiency of the affected extremity. When the arterial access site is used, the client is on strict bed rest for at least several hours. Fluids are encouraged after catheterization to increase urinary output and flush out the dye used during the procedure. There is no need to restrict dietary fiber. In fact, constipation can be dangerous for cardiac clients if they strain at stool (Valsalva maneuver.)
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