Med Surge week 4 questions

A client with multiple myeloma reports bone pain that is unrelieved by analgesics. What is the most appropriate response by the nurse? A. "Ask your doctor to prescribe more medication." B. "Would you like to try some relaxation techniques?" C. "I'll turn on some soothing classical music for you." D. "It is too soon for additional medication to be given."

B

A client with thrombocytopenia is being discharged. Which instruction would the nurse include in a teaching plan for this client? A. "Avoid large crowds." B. "Use a soft-bristled toothbrush." C. "Drink at least 2 L of fluid per day." D. "Elevate your lower extremities when sitting."

B

A patient with hypertension is discussing the cause of hypertension. Which statement by the nurse is appropriate? A. "Pregnancy can cause essential hypertension." B. "High cholesterol can be a big factor in the development of essential hypertension." C. "Stopping intake of caffeine can cause hypertension to go away." D. Race is associated with secondary hypertension.

B

For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? A. Heart rate 52 beats/min B. Blood pressure (BP) 192/102 mm Hg C. Report of constipation D. Anxiety

B

Which nursing intervention most effectively protects a client with thrombocytopenia? A. Take rectal temperatures B. Avoid the use of dentures C. Apply warm compresses on trauma sites D. Encourage the use of an electric shaver

D

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? A. "My leg might turn very white after the surgery." B. "I must be concerned if my foot turns blue." C. "I must report a fever or any drainage." D. "Warmness, redness, and swelling are expected."

A

A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the primary health care provider (PCP) immediately? A. Swelling and tenseness in the affected area B. Incisional pain and tenderness at the surgical site C. Pink, mobile fingers D. An order for heparin infusion

A

A patient with polycythemia vera is admitted with reports of shortness of breath, hypertension, and loss of pulses in her right foot. Which is the priority nursing intervention? A. Assess current hydration status B. Administer oxygen by nasal cannula C. Elevate her lower extremities on pillows D. Evaluate the patient for hypertensive crisis

A

The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? A. Urine output of 20 mL over 2 hours B. Blood pressure of 106/58 mm Hg C. Absent bowel sounds D. +3 pedal pulses

A

The nurse is assessing several clients who are receiving transfusions of blood components. Which assessment finding requires immediate action by the nurse? A. Respiratory rate of 36 breaths/min in a client receiving red blood cells B. Temperature of 99.1°F (37.3°C) for a client with a platelet transfusion C. Sleepiness in a client who received diphenhydramine (Benadryl) as a premedication D. A partial thromboplastin time (PTT) that is 1.2 times normal in a client who received a transfusion of fresh-frozen plasma (FFP)

A

The nurse is assigned to all of these clients. Which client would be assessed first? A. The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago B. The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg C. The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid D. The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

A

The nurse is caring for a client who is in sickle cell crisis. What action would the nurse perform first? A. Provide pain medications as needed. B. Apply cool compresses to the client's forehead. C. Increase food sources of iron in the client's diet. D. Encourage the client's use of two methods of birth control.

A

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? A. Reproducible leg pain with exercise B. Unilateral swelling of affected leg C. Decreased pain when legs are elevated D. Pulse oximetry reading of 90%

A

What is the priority nursing intervention in the care of an older patient with a history of diverticular disease and pernicious anemia? A. Preventing falls B. Monitoring intake and output C. Turning the patient every 2 hours D. Encouraging a diet high in vitamin B12

A

Which client does the medical unit charge nurse assign to a licensed practical nurse (LPN)/licensed vocational nurse (LVN)? A. A client with chronic microcytic anemia associated with alcohol use B. A client scheduled for a bone marrow biopsy with conscious sedation C. A client with a history of a splenectomy and a temperature of 100.9°F (38.3°C) D. A client with atrial fibrillation and an international normalized ratio of 6.6

A

Which task is appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) working on a medical-surgical unit? A. Obtain vital signs on a client receiving a blood transfusion B. Assist a client with folic acid deficiency in making diet choices C. Administer erythropoietin to a client with myelodysplastic syndrome D. Assess skin integrity on an anemic client who fell during ambulation

A

The nurse is performing an assessment on a client with anemia. What are the typical clinical manifestations of anemia? Select all that apply. A. Pallor B. Fatigue C. Tachycardia D. Dyspnea on exertion E. Elevated temperature F. Decreased breath sounds

A, B, C, D

What are the risk factors for the development of leukemia? Select all that apply. A. Down syndrome B. Chemical exposure C. Ionizing radiation D. Prematurity at birth E. Bone marrow hypoplasia F. Multiple blood transfusions

A, B, C, E

Which are risk factors that are known to contribute to atherosclerosis-related diseases? Select all that apply. A. Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL (4.14 mmol/L) B. Smoking C. Aspirin (acetylsalicylic acid [ASA]) consumption D. Type 2 diabetes E. Vegetarian diet

A, B, D

A distant family member arrives to visit a female client recently diagnosed with leukemia. The family member asks the nurse, "What should I say to her?" Which responses does the nurse suggest? Select all that apply. A. "Ask her how she is feeling." B. "Ask her if she needs anything." C. "Tell her to be brave and to not cry." D. "Tell her what you know about leukemia." E. "Talk to her as you normally would when you haven't seen her for a long time."

A, B, E

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? Select all that apply. A. Has maintained a low-sodium, no-added-salt diet B. Has lost 3 pounds (1.4 kg) since last seen in the clinic C. Cooks food in palm oil to save money D. Exercises once weekly E. Has cut down on caffeine

A, B, E

The nurse is teaching a client with newly diagnosed anemia about conserving energy. Which instructions would the nurse give to the client? Select all that apply . A. "Provide yourself with four to six small, easy-to-eat meals daily." B. "Perform your care activities in groups to conserve your energy." C. "Stop activity when shortness of breath or palpitations is present." D. "Allow others to perform your care during periods of extreme fatigue." E. "Drink small quantities of protein shakes and nutritional supplements daily." F. "Perform a complete bath daily to reduce your chance of getting an infection."

A, C, D, E

A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the primary health care provider (PCP)? A. Partial thromboplastin time (PTT) 60 seconds B. Platelets 32,000/mm3 (32 × 109/L) C. White blood cells 11,000/mm3 (11 × 109/L) D. Hemoglobin 12.2 g/dL (122 mmol/L)

B

A 23-year-old African-American male with a history of sickle cell disease had an emergent open reduction and internal fixation of his right femur after a car crash. What is the initial postoperative nursing priority? A. Treating the patient's pain B. Ensuring adequate IV hydration C. Titrating oxygen to an Spo2 > 95% D. Examining the surgical incision for signs and symptoms of infection

B

A client has a bone marrow biopsy performed. What is the priority postprocedure nursing action? A. Inspect the site for ecchymosis B. Apply pressure to the biopsy site C. Send the biopsy specimens to the laboratory D. Teach the client to avoid vigorous activity

B

A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan? A. Hypoxia B. Infection C. Hemorrhage D. Fluid overload (overhydration)

B

The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question would the nurse ask the client? A. "Can you prepare your own meals every day?" B. "How is your energy level compared with last year?" C. "Has your weight changed by 5 pounds (2.3 kg) or more this year?" D. What medications do you take daily, weekly, and monthly?"

B

The nurse is caring for a client with dark-colored toe ulcers and blood pressure (BP) of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? A. Assess leg ulcers for evidence of infection. B. Administer a clonidine patch for hypertension. C. Obtain a request from the health care provider for a dietary consult. D. Develop a plan for discharge, and assess home care needs.

B

The nurse is caring for four clients with a history of hypertension. Which client would require intervention? A. 40-year-old with chronic kidney disease, BP 138/80. B. 58-year-old on diuretics, BP 160/80 C. 28-year-old with LDL-C 140 mg/dL, BP 114/84 D. 30-year-old with pre-eclampsia, BP 120/68

B

The nurse is educating a group of young women who have sickle cell disease (SCD). Which statement from a class member indicates further teaching is necessary? A. "The pneumonia vaccine is protection that I need." B. "Getting an annual 'flu shot' would be dangerous for me." C. "I must take my penicillin pills as prescribed, all the time." D. "Frequent handwashing is an important habit for me to develop."

B

The nurse is starting the shift by making rounds. Which client would the nurse assess first? A. A 52-year-old who just had a bone marrow aspiration and is requesting pain medication B. A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism C. A 47-year-old who had a Rumpel-Leede test and asks the nurse to "look at the bruises on my arm" D. A 42-year-old with a diagnosis of anemia who reports shortness of breath when ambulating down the hallway

B

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? A. "I can use an electric razor or a regular razor." B. "Eating foods like green beans won't interfere with my Coumadin therapy." C. "If I notice I am bleeding a lot, I should stop taking Coumadin right away." D. "When taking Coumadin, I may notice some blood in my urine."

B

The nurse is teaching a client who is preparing for discharge after a bone marrow aspiration. The nurse provides which discharge instructions to the client? A. "Inspect the site for bleeding every 4 to 6 hours." B. "Place an ice pack over the site to reduce the bruising." C. "Avoid contact sports or activity that may traumatize the site for 24 hours." D. "Take a mild analgesic, such as two aspirin, for pain or discomfort at the site."

B

The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What electrolyte imbalance would the nurse monitor for after the blood transfusion? A. Hyponatremia B. Hyperkalemia C. Hypercalcemia D. Hypomagnesemia

B

The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet? A. Less than 30% of the daily caloric intake should be derived from proteins. B. Use canola oil rather than palm oil. C. Consume 10 mg of fiber daily. D. Work toward lowering your high-density lipoprotein (HDL) cholesterol levels.

B

What is the most important environmental risk for developing leukemia? A. Family history B. Smoking cigarettes C. Living near high-voltage power lines D. Direct contact with others with leukemia

B

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? A. Increase red meat in the diet. B. Consume melons and baked potatoes. C. Add several portions of dairy products each day. D. Try replacing your usual breakfast with oatmeal or Cream of Wheat.

B

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? A. "I feel my heart beating in my abdominal area." B. "I just started to feel a tearing pain in my belly." C. "I have a headache. May I have some acetaminophen?" D. "I have had hoarseness for a few weeks."

B

A 32-year-oldclient is recovering from a sickle cell crisis. The client's discomfort is controlled with pain medications and discharge planning has been initiated. What medication will the nurse anticipate to be prescribed before discharge? A. Heparin (Heparin) B. Warfarin (Coumadin) C. Hydroxyurea (Droxia) D. Tissue plasminogen activator (t-PA)

C

A client is scheduled for a bone marrow aspiration. What is the priority nursing action before this procedure is performed? A. Hold the client's hand and ask about concerns. B. Review the client's platelet (thrombocyte) count. C. Verify that the client has given informed consent. D. Clean the biopsy site with an antiseptic or povidone-iodine (Betadine).

C

A client on anticoagulant therapy is being discharged. Which statement by the client indicates an understanding of the anticoagulants drug action? A. "It will thin my blood." B. "It is used to dissolve blood clots." C. "It should prevent my blood from clotting." D. "It might cause me to get injured more often."

C

A client with anemia asks the nurse, "Do most people have the same number of red blood cells?" Which is the nurse's best response to the client? A. "Yes, they do." B. "No, they don't." C. "The number varies with gender, age, and general health." D. "You have fewer red blood cells because you have anemia."

C

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? A. Ankle-brachial index B. Dye allergy C. Pedal pulses D. Gag reflex

C

A client's medical record shows these data: Physical Assessment, Findings Diagnostic, Findings Provider ,Prescriptions Crackles at bases, PTT 55 seconds, Lovenox 40 mg twice daily, Right leg swelling, POSITIVE, D-dimer, Elevate right leg, Right calf pain, hCG negative, Doppler study right leg A. Human chorionic gonadotropin (hCG) negative B. Crackles at bases C. Positive D-dimer (>0.5mg/L) D. Right leg swelling

C

A hematology unit is staffed by registered nurse's (RNs), licensed practical nurses (LPNs)/licensed vocational nurse (LVNs), and unlicensed assistive personnel (UAP). When the nurse manager is reviewing staff documentation, which entry indicates the need for staff education for his or her appropriate level of responsibility and client care? A. "Abdominal pain relieved by morphine 4 mg IV; client resting comfortably and denies problems. B.C., RN" B. "Ambulated in hallway for 40 feet (12 m) and denies shortness of breath at rest or with ambulation. T.Y., LPN" C. "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" D. "Vital signs 98.6°F (37.0°C), heart rate 60, respiratory rate 20, blood pressure 110/68, and oximetry 98% on room air. L.D., UAP"

C

A newly admitted client has an elevated reticulocyte count. Which condition does the nurse suspect in this client? A. Leukemia B. Aplastic anemia C. Hemolytic anemia D. Infectious process

C

A patient is transitioning from IV heparin therapy to oral warfarin. Which laboratory finding does the nurse identify that confirms warfarin treatment efficacy? A. Bleeding time of 5 minutes B. Prothrombin time (PT) of 18 seconds C. International normalized ratio (INR) of 2.5 D. Partial thromboplastin time (PTT) of 24.3 seconds

C

After reviewing the laboratory test results, the nurse calls the primary care provider about which client? A. A 52-year-old who had a hemorrhage with a reticulocyte count of 0.8% B. A 49-year-old with hemophilia and a platelet count of 150,000/mm3 (150 × 109/L) C. A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 (1.5 × 109/L) D. A 44-year-old prescribed warfarin (Coumadin) with an international normalized ratio (INR) of 3.0

C

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? A. "Are you afraid you will not be able to work?" B. "If you control your diabetes, you can avoid amputation." C. "Your concerns are valid; we can review some steps to limit disease progression." D. "What about the situation concerns you most?"

C

The nurse assess the client with which hematologic condition first? A. A 32-year-old with pernicious anemia who needs a vitamin B12 injection B. A 67-year-old with acute myelocytic leukemia with petechiae on both legs C. An 81-year-old with thrombocytopenia and an increase in abdominal girth D. A 40-year-old with iron deficiency anemia who needs a Z-track iron injection

C

The nurse is assessing a client for hematologic risks. Which health history question would the nurse ask to determine if the risk cannot be reduced or eliminated? A. "Where do you work?" B. "Tell me what you eat in a day." C. "Does anyone in your family bleed a lot?" D. "Do you seem to have excessive bleeding or bruising?"

C

The nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? A. Uses a prepared list and finds out the client's food preferences B. Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) C. Has the client write down everything he or she has eaten for the past week D. Determines who prepares the client's meals and plans an interview with him or her

C

The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client would the nurse question? A. Enalapril (Vasotec) B. Sodium nitroprusside (Nipride) C. Dopamine (Intropin) D. Labetalol (Normodyne)

C

The nurse is caring for a group of hospitalized clients. Which client is at highest risk for infection and sepsis? A. A client with hemolytic anemia B. A client with cirrhosis of the liver C. A client who had an emergency splenectomy D. A client with recently diagnosed sickle cell anemia

C

The nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased laboratory value would be of greatest concern to the nurse because it is not age-related? A. Hemoglobin level B. Red blood cell (RBC) count C. Platelet (thrombocyte) count D. White blood cell (WBC) response

C

The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? A. "The doctor will place a small needle in your back and will withdraw some fluid." B. "You will be sedated during the procedure, so you will not be aware of anything." C. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." D. "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area."

C

The nurse is transfusing a unit of whole blood to a client when the primary health care provider prescribes "Furosemide (Lasix) 20 mg IV push." Which intervention would the nurse perform? A. Piggyback the furosemide into the infusing blood. B. Give furosemide to the client intramuscularly (IM). C. Administer the furosemide after completion of the transfusion. D. Add furosemide to the normal saline that is infusing with the blood.

C

The nurse performs an assessment on a newly admitted client with thrombocytopenia. Which assessment finding requires immediate intervention by the nurse? A. Reports of pain B. Increased temperature C. Bleeding from the nose D. Decreased urine output

C

Which sign/symptom is essential for the nurse to report to the primary health care provider (PCP) when caring for a client with Raynaud's phenomenon? A. Nifedipine (Procardia) administration caused the blood pressure to change from 134/76 to 110/68 mm Hg. B. The client's extremity became white, then red temporarily. C. The affected extremity becomes purple and cold. D. The client states that the digits are painful when they are white.

C

Which symptom reported by a client who has had a total hip replacement requires emergency action? A. Localized swelling of one of the lower extremities B. Positive Homans' sign C. Shortness of breath and chest pain D. Tenderness and redness at the IV site

C

Which task does the nurse delegate to unlicensed assistive personnel (UAP)? A, Refer a client with a daily alcohol consumption of 12 beers for counseling B. Obtain a partial thromboplastin time from a saline lock on a client with a pulmonary embolism C. Report any bleeding noted when catheter care is given to a client with a history of hemophilia D. Perform a capillary fragility test to check vascular hemostatic function on a client with liver failure

C

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? A. "Elevate your legs above heart level to prevent swelling." B. "Inspect your legs daily for brownish discoloration around the ankles." C. "Walk to the point of leg pain, then rest, resuming when pain stops." D. "Apply a heating pad to the legs if they feel cold."

C

A client recovering from a sickle cell crisis is to be discharged. The nurse says to the client, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Cefaclor (Ceclor) B. Vancomycin (Vancocin) C. Gentamicin (Garamycin) D. Penicillin V (Pen-V K)

D

A client with a low platelet count asks the nurse, "Why are platelets important?" Which statement is the nurse's best response? A. "Platelets will make your blood clot." B. "Your platelets finish the clotting process." C. "Blood clotting is prevented by your platelets." D. "The clotting process begins with your platelets."

D

A client with anemia asks the nurse, "Why am I feeling tired all the time?" What is the nurse's best response? A, "You are not getting enough iron." B. "When you are sick you need to rest more." C. "How many hours are you sleeping at night?" D. "Your cells are delivering less oxygen than you need."

D

A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client? A. "Consume foods high in potassium." B. "Monitor for irregular pulse." C. "Monitor for muscle cramping." D. "Avoid grapefruit juice."

D

A client with leukemia is being discharged from the hospital. The nurse's discharge instructions say to keep regularly scheduled follow-up primary health care provider appointments. The client says, "I don't have transportation." Which is the most appropriate nursing response? A. "You can take the bus." B. "I might be able to take you." C. "A pharmaceutical company might be able to help." D. "The local American Cancer Society may be able to help."

D

A pediatric nurse is floated to a medical-surgical unit. Which client is assigned to the float nurse? A. A 60-year-old with newly diagnosed polycythemia vera who needs teaching about the disease B. A 50-year-old with pancytopenia needing assessment of risk factors for aplastic anemia C. A 55-year-old with folic acid deficiency anemia caused by alcohol abuse who needs counseling D. A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells

D

A recently admitted client who is in sickle cell crisis requests "something for pain." What medication would the nurse be prepared to administer? A. Oral ibuprofen (Motrin) B. Oral morphine sulfate (MS-Contin) C. Intramuscular (IM) morphine sulfate D. Intravenous (IV) hydromorphone (Dilaudid)

D

All of these client assignments have been made by the charge nurse. Which assignment is questionable? A. The RN with 3 years of experience caring for a client with a pulmonary embolism (PE) who is receiving heparin therapy B. The LPN/LVN with 5 years of experience caring for a client with leg ulcers who is awaiting nursing home placement C. The RN with 8 years of experience caring for a client with peripheral arterial disease (PAD) and a total cholesterol of 390 mg/dL (10.1 mmol/L) D. The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure (BP) is 210/150 mm Hg

D

The nurse is assessing the endurance level of a client in a long-term care facility. What question does the nurse ask to get this information? A. "How much exercise do you get?" B. "What is your endurance level?" C. "Are your feet or hands cold, even when you are in bed?" D. "Do you feel more tired after you get up and go to the bathroom?"

D

The nurse is teaching a client about induction therapy for acute leukemia. Which client statement indicates a need for additional education? A. "I will need to avoid people with a cold or flu." B. "I will probably lose my hair during this therapy." C. "The goal of this therapy is to put me in remission." D. "After this therapy, I will not need to have any more."

D

The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? A. "I must stop taking my birth control pills." B. "I should drink lots of water so I don't get dehydrated." C. "I should exercise my legs when I have been sitting or standing for a long time." D. "If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

D

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension? A. Psychiatric disturbance B. High sodium intake C. Physical inactivity D. Kidney disease

D

What is the most common symptom when a patient is diagnosed with hypertension? A. Headache B. Slurred speech C. Fainting and dizziness D. Hypertension is often asymptomatic

D

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A. A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness B. A 64-year-old with chronic venous ulcers who has a temperature of 100.1°F (37.8°C) C. A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness D. A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

D

Which finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation? A. Peptic ulcer disease B. Deep vein thrombosis (DVT) C. Osteoarthritis D. Marfan syndrome

D

Which task does the nurse delegate to unlicensed assistive personnel (UAP) who is assisting with the care of a female client with anemia? A. Monitor the oral mucosa for pallor, bleeding, or ulceration B. Ask about the amount of blood loss with each menstrual period C. Check for sternal tenderness while applying fingertip pressure D. Count the respiratory rate before and after ambulating 20 feet (6 m)

D

Which vascular assessment by the student nurse requires intervention by the supervising nurse? A. Measuring capillary refill in the fingertips B. Assessing pedal pulses by Doppler C. Measuring blood pressure in both arms D. Simultaneously palpating the bilateral carotids

D

While caring for a client who has received recombinant tissue plasminogen activator (t-PA) for a large deep vein thrombus, the nurse becomes most concerned when the client develops which condition? A. Small amount of blood at the IV insertion site B. Heavy menstrual bleeding C. +1 pitting edema of the affected extremity D. Client stating that the year is 1967

D

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? Select all that apply. A. Hypertension B. Tachycardia C. Bounding right pedal pulses D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg

D, E, F