A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?
A. "I will wear gloves when removing food from the freezer."
B. "I w...
NURS 402 - Exam 4 Questions with correct answers
A nurse is instructing a client who has a new diagnosis of Raynaud's
disease about preventing the onset of manifestations. Which of the
following client statements should indicate to the nurse the need for
additional teaching?
A. "I will wear gloves when removing food from the freezer."
B. "I will try to anticipate and avoid stressful situations when possible."
C. "I will complete the smoking cessation program I started."
D. "I will take my medications at the first sign of an attack." Correct
Answer-D
A nurse is caring for a client who has peripheral vascular disease and
reports difficulty sleeping because of cold feet. Which of the following
nursing actions should the nurse take to promote the client's comfort?
A. Obtain a pair of slipper-socks for the client.
B. Rub the client's feet briskly for several minutes.
C. Increase the client's oral fluid intake.
D. Place a moist heating pad under the client's feet. Correct Answer-A
A nurse is administering a cold therapy application to a client. Which of
the following manifestations should the nurse identify as an indication
for discontinuing the application due to a systemic response?
A. Hypotension
,B. Numbness
C. Shivering
D. Reduced blood viscosity Correct Answer-C
A nurse is caring for a client who has deep-vein thrombosis and is
receiving IV fluid that contains 10,000 units of heparin in 500 mL
infusing at 1,000 units/hr. When calculating the client's intake and
output, how much should the nurse document as intake from this
infusion in an 8-hr shift? (Round the answer to the nearest whole
number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer-400 ml
A nurse is measuring a client for knee-high anti-embolic stockings to
help prevent venous stasis. Which of the following actions should the
nurse take?
A. Measure from the heel to the gluteal fold.
B. Measure the length of the feet.
C. Measure from the heel to the popliteal space.
D. Measure the ankle circumference. Correct Answer-C
A nurse is providing preoperative teaching for a client who will undergo
surgery. The nurse explains that the client will wear antiembolism
stockings during and after the procedure. When the client asks what the
stockings do, which of the following responses should the nurse make?
A. "They protect your legs and heels from skin breakdown."
,B. They help keep you warm after your surgery."
C. "They improve your circulation to keep blood from pooling in your
legs."
D. "They make it easier for you to do leg exercises after your surgery."
Correct Answer-C
A nurse is assessing a client for pitting edema and notes an indentation
of 6 mm (0.25 in) at the point of pressure. Which of the following
notations should the nurse use to document the severity of the client's
edema?
A. 4+
B. 3+
C. 2+
D. 1+ Correct Answer-B
A nurse is caring for a client who is postoperative and has a prescription
for anti-embolic stockings. Which of the following actions should the
nurse take?
A. Apply the stockings while the client is sitting in a chair.
B. Remove the stockings once each day.
C. Check the stockings for wrinkles.
D. Measure the size of the client's foot. Correct Answer-C
, While performing an admission assessment for a client, the nurse notes
that the client has varicose veins with ulcerations and lower extremity
edema with a report of a feeling of heaviness. Which of the following
nursing diagnoses should the nurse identify as being the priority in the
client's care?
A. Impaired tissue perfusion
B. Alteration in body image
C. Alteration in activity tolerance
D. Impaired skin integrity Correct Answer-A
A nurse is caring for a client who is postoperative and is at risk for
developing venous thromboembolism (VTE). The nurse should instruct
the client to avoid which of the following unsafe actions?
A. Elevating her feet
B. Massaging her legs
C. Flexing her ankles
D. Ambulating soon after surgery Correct Answer-B
A nurse is assessing a client's radial pulse and determines that the pulse
is irregular. Which of the following actions should the nurse take?
A. Assess the apical pulse for a full minute.
B. Assess the apical pulse with a Doppler device.
C. Assess the pedal pulses for a full minute.
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