Question

A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

Answer 1

Correct Answers:

"I will wear stockings with elastic tops."

Rationale :

🔶 Elastic-top stockings can impede venous return and worsen peripheral vascular disease (PVD).

🔶 Constriction from tight bands may reduce circulation and elevate risk of skin breakdown.

🔶 Clients with PVD require unrestricted blood flow to avoid complications like ulcers.

🔶 Education should emphasize non-constrictive clothing to promote circulation.

🔶 Stockings prescribed for PVD are typically graduated compression, not elastic-topped.

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Answer 2

Correct Answers:

Irregular

Rationale :

🔶 Atrial fibrillation causes disorganized atrial impulses, resulting in an irregularly irregular pulse.

🔶 The ventricles receive inconsistent signals, leading to a varying rhythm and rate.

🔶 The pulse is palpable, but the rhythm lacks a pattern.

🔶 Irregular pulse is a key clinical indicator of atrial fibrillation.

🔶 Documentation must reflect the pulse quality accurately for treatment decisions.

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Answer 3

Correct Answers:

Instruct the client to call 911.

Rationale :

🔷 Persistent chest pain after nitroglycerin may indicate myocardial infarction (MI), requiring emergency care.

🔷 Nitroglycerin should relieve angina within minutes; failure to respond signals a more serious cardiac event.

🔷 Calling 911 ensures immediate EMS support, including defibrillation if needed.

🔷 Clients should be taught to call 911 if pain persists after one dose.

🔷 Repeating nitroglycerin every 5 minutes up to 3 doses is acceptable only if EMS is already activated.

🔷 Delay in seeking help can increase myocardial damage or risk of sudden death.

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Answer 4

Correct Answers:

Turkey sandwich on whole wheat bread, green beans, and banana

Rationale :

🟢 The DASH diet promotes low sodium, low saturated fat, and high fiber intake.

🟢 This option includes lean protein, whole grains, and fruits/vegetables, aligning with DASH principles.

🟢 It avoids processed or fried foods that are high in cholesterol and sodium.

🟢 Whole milk and pork sausage in other options are too high in fat and salt.

🟢 DASH helps reduce blood pressure and risk of cardiovascular disease.

🟢 The banana provides potassium, which supports BP control.

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Answer 5

Correct Answers:

Heart murmur

Rationale :

🔴 Mitral stenosis causes turbulent blood flow through the narrowed valve, producing a murmur.

🔴 This is typically a diastolic murmur best heard at the apex.

🔴 Barrel chest is linked with lung diseases, not cardiac valve disorders.

🔴 Clubbing and bradycardia are nonspecific and not expected findings in mitral stenosis.

🔴 Detection of a murmur often prompts echocardiography to confirm valve defects.

🔴 Symptoms may include fatigue and dyspnea due to reduced cardiac output.

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Answer 6

Correct Answers:

Troponin T test

Rationale :

🟣 Troponin T is the most specific and early indicator of myocardial injury.

🟣 Levels begin to rise within 2–4 hours and stay elevated up to 2 weeks.

🟣 It is more sensitive and cardiac-specific than CK-MB or total CK.

🟣 Helps distinguish cardiac muscle injury from skeletal muscle injury.

🟣 A key lab test in diagnosing acute myocardial infarction (AMI).

🟣 BNP is used for heart failure, not for detecting early cardiac injury.

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Answer 7

Correct Answers:

Decreased blood flow to the area can cause the wound and decrease the healing.

Rationale :

🟠 In PAD, arterial occlusion leads to poor perfusion, especially in lower extremities.

🟠 Ischemia delays healing and contributes to ulcer formation.

🟠 Arterial ulcers are usually painful, pale, and located on toes or feet.

🟠 Unlike venous ulcers, they do not typically involve edema.

🟠 Managing PAD includes improving circulation through medications and lifestyle changes.

🟠 Adequate oxygenation is essential for wound healing and tissue regeneration.

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Answer 8

Correct Answers:

Troponin T

Rationale :

🔵 Troponin T remains elevated for 10–14 days after a myocardial infarction.

🔵 Other markers like CK-MB and myoglobin normalize within 2–3 days.

🔵 Useful for detecting late myocardial damage or reinfarction.

🔵 Allows providers to track recovery progress post-MI.

🔵 The most reliable long-term indicator of cardiac injury.

🔵 Blood samples may still detect ongoing myocardial cell death.

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Answer 9

Correct Answers:

Potassium 2.3 mEq/L

Rationale :

⚫ Bumetanide is a loop diuretic that promotes potassium loss.

⚫ Hypokalemia (<3.5 mEq/L) increases the risk of cardiac dysrhythmias.

⚫ A level of 2.3 mEq/L is critically low and must be corrected immediately.

⚫ Monitor ECG for flattened T waves or U waves.

⚫ Low potassium can also cause muscle weakness and cramping.

⚫ Electrolytes must be monitored frequently in clients on loop diuretics

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Answer 10

Correct Answers:

Decreased deep-tendon reflexes

Rationale :

🟠 Hypokalemia impairs neuromuscular activity, leading to reduced reflexes.

🟠 Also causes weakness, cramps, and fatigue.

🟠 May lead to cardiac arrhythmias, requiring ECG monitoring.

🟠 Caused by potassium-wasting diuretics like chlorothiazide.

🟠 Assessment of reflexes helps identify early electrolyte imbalances.

🟠 Timely potassium replacement is crucial to avoid complications

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QLexNursing

1 :
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

2 :
A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?

3 :
A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

4 :
A nurse is reinforcing teaching to a client who has a chronic illness about the DASH diet. Which of the following meals best fits the DASH diet?

5 :
A nurse is collecting data on a client who has mitral valve stenosis. Which of the following findings should the nurse expect?

6 :
A nurse is collecting data for a client who experienced a myocardial infarction prior to a cardiac arrest. Which of the following laboratory tests will identify early injury to the cardiac muscle?

7 :
A nurse is caring for a client with peripheral artery disease who has an arterial ulcer. Which of the following best describes the mechanism for developing the clinical problem?

8 :
A nurse is reviewing the laboratory findings of a client who experienced an acute myocardial infarction 6 days ago. Which of the following laboratory values should the nurse expect to remain elevated at this time?

9 :
A nurse is reviewing the laboratory values for a client who has heart failure and is taking bumetanide. For which of the following results should the nurse notify the provider?

10 :
A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia?

QLexNursing

1 : A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

2 : A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?

3 : A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

4 : A nurse is reinforcing teaching to a client who has a chronic illness about the DASH diet. Which of the following meals best fits the DASH diet?

5 : A nurse is collecting data on a client who has mitral valve stenosis. Which of the following findings should the nurse expect?

6 : A nurse is collecting data for a client who experienced a myocardial infarction prior to a cardiac arrest. Which of the following laboratory tests will identify early injury to the cardiac muscle?

7 : A nurse is caring for a client with peripheral artery disease who has an arterial ulcer. Which of the following best describes the mechanism for developing the clinical problem?

8 : A nurse is reviewing the laboratory findings of a client who experienced an acute myocardial infarction 6 days ago. Which of the following laboratory values should the nurse expect to remain elevated at this time?

9 : A nurse is reviewing the laboratory values for a client who has heart failure and is taking bumetanide. For which of the following results should the nurse notify the provider?

10 : A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia?

1 :
A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

2 :
A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?

3 :
A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

4 :
A nurse is reinforcing teaching to a client who has a chronic illness about the DASH diet. Which of the following meals best fits the DASH diet?

5 :
A nurse is collecting data on a client who has mitral valve stenosis. Which of the following findings should the nurse expect?

6 :
A nurse is collecting data for a client who experienced a myocardial infarction prior to a cardiac arrest. Which of the following laboratory tests will identify early injury to the cardiac muscle?

7 :
A nurse is caring for a client with peripheral artery disease who has an arterial ulcer. Which of the following best describes the mechanism for developing the clinical problem?

8 :
A nurse is reviewing the laboratory findings of a client who experienced an acute myocardial infarction 6 days ago. Which of the following laboratory values should the nurse expect to remain elevated at this time?

9 :
A nurse is reviewing the laboratory values for a client who has heart failure and is taking bumetanide. For which of the following results should the nurse notify the provider?

10 :
A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia?