Question

A nurse is caring for a client who is I day postoperative following a femoral popliteal bypass graft. The nurse notes a diminished pedal pulse while assessing the right leg. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Assess pedal pulse on left leg

Rationale :

🔷 Comparing the right leg pulse with the left leg pulse establishes whether the change is unilateral, which helps determine if the graft is compromised.

🔷 A diminished pulse in the operative leg may indicate graft occlusion, a surgical emergency requiring immediate evaluation.

🔷 Baseline comparison is essential, because the nurse must determine whether the diminished pulse is new or part of the client’s chronic vascular pattern.

🔷 Prompt assessment of both extremities helps identify impaired perfusion, which is the highest priority following vascular bypass surgery.

🔷 Early detection of graft failure greatly improves outcomes, making bilateral pulse assessment the most critical next step.

Elevate the right leg on pillows.

🔷 Elevation can reduce arterial blood flow, which may further compromise perfusion to an already ischemic limb.

🔷 Arterial bypass grafts require dependent positioning, not elevation, when perfusion is threatened.

Assist the client to ambulate.

🔷 Ambulation will not correct a diminished pulse, and may worsen ischemia or damage the graft.

🔷 Activity is contraindicated until perfusion is confirmed, because graft compromise requires immediate medical evaluation.

Assess surgical incision site for infection.

🔷 Infection does not cause an immediate diminished pulse, so this does not address the urgent perfusion concern.

🔷 Pulse changes indicate vascular compromise, not infection, making incision assessment a lower priority.

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Answer 2

Correct Answers

Blank 1 Correct Option: Cirrhosis
Blank 2 Correct Option: Measure the abdominal girth and Teach the client about restricting sodium intake
Blank 3 Correct Option: Ammonia levels and Unintentional weight loss

Rationale :

🔷 The client’s symptoms—ascites, hepatomegaly, distended abdominal veins, edema, and dyspnea—are classic manifestations of cirrhosis, indicating severe hepatic congestion and portal hypertension.

🔷 Measuring abdominal girth is essential, because it allows the nurse to track ascites progression and evaluate response to diuretic therapy or sodium restriction.

🔷 Teaching sodium restriction is critical, since lowering sodium reduces fluid retention and helps manage ascites and peripheral edema.

🔷 Ammonia levels must be monitored, because impaired hepatic function can lead to hepatic encephalopathy, especially in clients showing altered mental status or dyspnea.

🔷 Monitoring for unintentional weight loss evaluates nutritional status, which is often compromised in cirrhosis due to poor absorption, early satiety, and metabolic changes.

Celiac disease

🔷 This condition does not cause ascites, hepatomegaly, or distended abdominal veins.

🔷 Crackles, edema, and portal hypertension are not associated with celiac disease.

Crohn’s disease

🔷 Crohn’s disease causes abdominal pain and diarrhea, not massive ascites or venous distention.

🔷 Hepatomegaly and pitting edema are not typical findings.

Pancreatitis

🔷 Pancreatitis presents with severe abdominal pain, nausea, and vomiting, which the client denies.

🔷 Ascites and abdominal venous distention are uncommon early signs.

Manage pain control

🔷 Pain is not the priority, as the client denies abdominal pain.

🔷 The priority relates to respiratory compromise and fluid excess.

Assess amylase and lipase levels

🔷 These labs evaluate pancreatitis, which is not supported by this client’s symptoms.

🔷 The client’s abdominal findings point toward liver disease rather than pancreatic injury.

Teach the client how to identify sources of gluten

🔷 Gluten education applies to celiac disease, not cirrhosis.

🔷 This teaching does not address fluid retention or hepatic dysfunction.

Diet adherence to prevent exacerbations

🔷 Cirrhosis monitoring focuses on fluid status and hepatic function, not daily diet adherence like in Crohn’s or celiac disease.

🔷 Diet tracking does not monitor disease progression directly.

Amylase and lipase levels

🔷 These labs assess pancreatic inflammation, irrelevant to the client’s liver-based symptoms.

🔷 They do not help track ascites or hepatic encephalopathy.

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Answer 3

Correct Answers

Blank 1 Correct Option: System lupus erythematosus
Blank 2 Correct Option: Help client to identify factors that aggravate symptoms and Instruct client to wear long sleeves and a hat when outdoors
Blank 3 Correct Option: Adherence to corticosteroid therapy and Depression due to body image disturbance

Rationale :

🔷 The positive ANA, elevated ESR, anemia, and joint tenderness strongly indicate systemic inflammation, which is characteristic of systemic lupus erythematosus.

🔷 The butterfly rash, alopecia, mouth ulcers, and hyperpigmented lesions are classic SLE manifestations, confirming this autoimmune diagnosis.

🔷 Teaching avoidance of sunlight is essential, because ultraviolet exposure can trigger flares and worsen skin lesions.

🔷 Helping the client identify flare triggers improves self-management, reducing the frequency and severity of exacerbations.

🔷 Monitoring corticosteroid adherence is critical, because steroids control inflammation and prevent life-threatening complications such as renal involvement.

Celiac disease

🔷 Celiac disease presents with gastrointestinal symptoms, not butterfly rash, alopecia, or joint edema.

🔷 ANA positivity and systemic inflammation are not characteristic findings.

Type 1 diabetes mellitus

🔷 This condition does not cause skin plaques, rash, or mucosal ulcerations, which are prominent in SLE.

🔷 ANA and ESR abnormalities do not indicate diabetes.

Multiple sclerosis

🔷 MS presents with neurological deficits, not cutaneous rashes, joint edema, or mouth ulcers.

🔷 The lab findings do not support demyelinating disease.

Recommend low-impact and strength-building exercises

🔷 Exercise is beneficial but not a priority action, compared to reducing flare triggers and UV exposure.

🔷 Activity guidance does not address the acute systemic inflammation.

Educate client on carbohydrate counting

🔷 This applies to diabetes management, not SLE.

🔷 It does not reduce lupus flare risk.

Remind client to read food labels for gluten

🔷 This is relevant to celiac disease, not SLE.

🔷 Gluten avoidance does not affect lupus symptoms.

Diet adherence to prevent exacerbations

🔷 Diet is not the main driver of lupus flares, unlike in celiac or Crohn's disease.

🔷 Monitoring focuses more on medication adherence and emotional well-being.

Microvascular complications

🔷 These are associated with diabetes, not lupus.

🔷 SLE complications involve kidneys, skin, joints, and immune system—not microvasculature.

Changes in cognition

🔷 Cognitive changes are more closely linked to neurological disorders, not this client’s presentation.

🔷 No current symptoms indicate CNS involvement.

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Answer 4

Correct Answers:

Review the medical record for type and crossmatch information.

Rationale :

🔷 Type and crossmatch verification is essential, because the nurse must confirm compatibility before any blood product can be safely administered.

🔷 A hemoglobin of 7.2 g/dL indicates the need for transfusion, and checking type and crossmatch ensures the correct blood is ordered and matched for the client.

🔷 Reviewing the chart prevents transfusion reactions, which can occur if mismatched blood is given.

🔷 This is the priority before obtaining blood or preparing equipment, since no step can proceed without confirming compatibility status.

🔷 Early verification also prevents delays, ensuring that the transfusion is administered safely and promptly.

Prime the tubing with lactated Ringer’s

🔷 LR is not used to prime blood tubing

🔷 Normal saline is the only approved solution for priming and administering blood products.

Obtain the blood from the blood bank prior to inserting the peripheral catheter

🔷 Blood should not be retrieved until everything is ready for immediate transfusion

🔷 Blood must be hung quickly to avoid warming and bacterial growth.

Identify the client using their full name and room number

🔷 Room numbers are not acceptable identifiers

🔷 Only two approved identifiers (name + DOB or ID number) can be used for transfusion verification.

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Answer 5

Correct Answers

Weigh the client daily. [ Anticipated ]
Begin a 24-hr urine collection. [ Nonessential ]
Decrease oxygen to 1 L/min. [ Contraindicated ]
Increase the dosage of furosemide. [ Anticipated ]
Restrict the client's fluid intake to 2 L/day. [ Anticipated ]
Hold the client’s metoprolol. [ Contraindicated ]

Rationale :

🟦 Daily weights reflect fluid retention, which is the most accurate indicator of worsening or improving heart failure.

🟦 Increasing furosemide is essential, because the client has fluid overload evidenced by weight gain and declining oxygen saturation.

🟦 Fluid restriction reduces preload, helping control pulmonary and peripheral edema.

🟦 BNP of 400 indicates high cardiac strain, making diuresis and fluid restriction important interventions.

🟦 Maintaining oxygenation is critical, and interventions meant to improve perfusion (diuresis + oxygen) directly support stabilization.

Begin a 24-hr urine collection

🟦 This test does not address acute fluid overload, which requires immediate management.

🟦 The client’s priority is stabilizing respiratory and cardiac status, not collecting long-term urine output data.

Decrease oxygen to 1 L/min

🟦 Oxygen saturation is worsening, so lowering oxygen would further reduce perfusion.

🟦 HF with pulmonary congestion requires maintaining or increasing oxygen, not reducing it.

Hold the client’s metoprolol

🟦 The client has atrial fibrillation with HR >110, so metoprolol is needed for rate control.

🟦 Stopping metoprolol increases risk of tachyarrhythmias and decreased cardiac output.

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Answer 6

Correct Answers:

Erythema surrounding the wound

Rationale :

🟥 Erythema indicates localized inflammation, which is one of the earliest visual signs of wound infection.

🟥 Infection increases capillary permeability, causing redness to spread beyond expected healing margins.

🟥 Redness combined with warmth or tenderness suggests pathogen activity, even before drainage becomes purulent.

🟥 Postoperative wounds should show controlled healing, so expanding erythema signals abnormal immune response.

🟥 Recognizing erythema early prevents worsening infection, including cellulitis or wound dehiscence.

Tissue inside the wound is pink

🟥 Pink tissue reflects healthy perfusion

It indicates normal healing, not infection.

Granulation tissue at wound edges

🟥 Granulation tissue is a positive healing sign

It shows new tissue growth and vascularization.

Serosanguinous wound drainage

🟥 Serosanguinous drainage is expected early

It is normal postoperative drainage unless amount or odor changes.

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Answer 7

Correct Answers:

Monitor site each shift.

Rationale :

🟨 Monitoring the pin site each shift detects early signs of infection, which is a major complication of skeletal traction.

🟨 Regular assessment identifies drainage, redness, or loosening, allowing prompt intervention before serious complications occur.

🟨 Pin site evaluation helps maintain traction integrity, ensuring the device remains stable and functional.

🟨 Frequent monitoring supports skin integrity, preventing breakdown around insertion areas.

🟨 Early detection of issues reduces risk of osteomyelitis, a severe infection that can occur from neglected pin sites.

Ensure traction weights are placed securely on the floor

🟨 Traction weights should never touch the floor

Weights must hang freely to maintain consistent pulling force.

Check neurovascular status twice daily

🟨 Neurovascular checks must be performed more frequently

In traction, assessments are typically done every 1–2 hours initially, not just twice daily.

Remove traction weights when providing ADLs

🟨 Traction weights must never be removed

Removing weights disrupts alignment and can cause injury or bone displacement.

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Answer 8

Correct Answers:

“Treatment of outbreaks can include oral and topical meditations."

Rationale :

🟪 HSV-2 outbreaks are managed with antiviral medications, which may be given orally or applied topically depending on severity.

🟪 Oral antivirals shorten outbreak duration, reduce viral shedding, and help control symptom intensity.

🟪 Topical antiviral agents provide localized relief, especially when lesions are painful or irritated.

🟪 Combination therapy may be used during severe outbreaks, improving comfort and healing.

🟪 Client education on treatment options empowers self-management, helping them recognize early symptoms and start therapy promptly.

“Use oil-based lubricants during outbreaks to treat pain with intercourse.”

🟪 Oil-based products can irritate lesions

They may worsen symptoms and also degrade condoms, increasing transmission risk.

“Antiviral medications taken daily will prevent transmission.”

🟪 Daily antivirals reduce but do not eliminate transmission risk

Clients can still transmit HSV-2 during asymptomatic viral shedding.

“Cryotherapy can decrease the likelihood that the vesicles will cause cancer.”

🟪 HSV-2 does not cause cancer

Cryotherapy is not used for genital herpes and will not reduce cancer risk.

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Answer 9

Correct Answers:

“You can wear a support bra to bed to help reduce pain.”

Rationale :

🟧 Wearing a supportive bra reduces breast discomfort, especially during times of increased nodularity from fibrocystic changes.

🟧 Continuous support minimizes breast movement, which helps decrease pain and tenderness.

🟧 Nighttime support is recommended, as hormonal breast changes can make lying down more painful.

🟧 This is a noninvasive, low-risk comfort measure, suitable for young women with benign breast changes.

🟧 Supportive garments help during symptomatic days, especially during the luteal phase when swelling increases.

“You will need to have a 3D mammogram annually.”

🟧 Annual mammograms are not required for fibrocystic changes

Routine imaging is based on age and risk, not benign lumps alone.

“You can expect to have more breast pain during the week after menses.”

🟧 Fibrocystic pain increases BEFORE menses, not after

Symptoms typically peak during the luteal phase due to hormonal stimulation.

“You will take tamoxifen until menopause to control your symptoms.”

🟧 Tamoxifen is not standard treatment for fibrocystic changes

It is reserved for specific breast cancer risk reduction, not benign cyclic pain.

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Answer 10

Correct Answers:

Reduced cravings

Rationale :

🔶 Methadone decreases opioid cravings, which indicates that the medication is achieving its intended therapeutic effect for opioid use disorder.

🔶 Reduced cravings help stabilize the client’s recovery process by lowering the urge to use illicit opioids.

🔶 Methadone provides controlled, steady opioid receptor activation, preventing the withdrawal distress that drives cravings.

🔶 A decrease in cravings allows the client to participate in counseling, daily activities, and long-term treatment more effectively.

🔶 This effect reflects proper dosing, meaning the client’s withdrawal symptoms and desire for opioids are being safely managed.

Dilated pupils

🔶 Dilated pupils indicate opioid withdrawal, not therapeutic effect of methadone.

🔶 Effective methadone therapy stabilizes the client so withdrawal signs are not present.

Euphoria

🔶 Euphoria is a sign of opioid intoxication, not controlled therapy.

🔶 Methadone should prevent highs, not cause them.

Somnolence

🔶 Somnolence suggests oversedation or toxicity.

🔶 This is unsafe and is not a desired therapeutic outcome of methadone.

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options	Anticipated	Nonessential	Contraindicated
Weigh the client daily.
Begin a 24-hr urine collection.
Decrease oxygen to 1 L/min.
Increase the dosage of furosemide.
Restrict the client's fluid intake to 2 L/day.
Hold the client’s metoprolol.

RN Adult Medical Surgical 2023 Dec

No.

1 :
A nurse is caring for a client who is I day postoperative following a femoral popliteal bypass graft. The nurse notes a diminished pedal pulse while assessing the right leg. Which of the following actions should the nurse take?

2 :
A nurse in an emergency department (ED) is caring for a client.

Correct Answers

3 :
A nurse in a provider's office is caring for a client.

Correct Answers

4 :
hemoglobin of 7.2 g/dL (12 to 16 g/dL). Which of the following actions should the nurse take?

5 :
A nurse is caring for a client who has heart failure.

Correct Answers

6 :
A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings indicates a possible wound infection?

7 :
A nurse is caring for a client who has skeletal traction on their leg. Which of the following actions should the nurse take?

8 :
A nurse is providing education about treatment options for a client who has genital herpes simplex virus 2 (HSV-2). Which of the following information should the nurse include?

9 :
A nurse is providing teaching to a young adult female client about fibrocystic changes in the breast. Which of the following statements should the nurse make?

10 :
A nurse is caring for a client who is receiving methadone therapy as treatment for an opioid use disorder. Which of the following findings should indicate to the nurse that the client is experiencing the therapeutic effects of this medication?

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RN Adult Medical Surgical 2023 Dec

No.

1 : A nurse is caring for a client who is I day postoperative following a femoral popliteal bypass graft. The nurse notes a diminished pedal pulse while assessing the right leg. Which of the following actions should the nurse take?

2 : A nurse in an emergency department (ED) is caring for a client.

Correct Answers

3 : A nurse in a provider's office is caring for a client.

Correct Answers

4 : hemoglobin of 7.2 g/dL (12 to 16 g/dL). Which of the following actions should the nurse take?

5 : A nurse is caring for a client who has heart failure.

Correct Answers

6 : A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings indicates a possible wound infection?

7 : A nurse is caring for a client who has skeletal traction on their leg. Which of the following actions should the nurse take?

8 : A nurse is providing education about treatment options for a client who has genital herpes simplex virus 2 (HSV-2). Which of the following information should the nurse include?

9 : A nurse is providing teaching to a young adult female client about fibrocystic changes in the breast. Which of the following statements should the nurse make?

10 : A nurse is caring for a client who is receiving methadone therapy as treatment for an opioid use disorder. Which of the following findings should indicate to the nurse that the client is experiencing the therapeutic effects of this medication?

1 :
A nurse is caring for a client who is I day postoperative following a femoral popliteal bypass graft. The nurse notes a diminished pedal pulse while assessing the right leg. Which of the following actions should the nurse take?

2 :
A nurse in an emergency department (ED) is caring for a client.

3 :
A nurse in a provider's office is caring for a client.

4 :
hemoglobin of 7.2 g/dL (12 to 16 g/dL). Which of the following actions should the nurse take?

5 :
A nurse is caring for a client who has heart failure.

6 :
A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings indicates a possible wound infection?

7 :
A nurse is caring for a client who has skeletal traction on their leg. Which of the following actions should the nurse take?

8 :
A nurse is providing education about treatment options for a client who has genital herpes simplex virus 2 (HSV-2). Which of the following information should the nurse include?

9 :
A nurse is providing teaching to a young adult female client about fibrocystic changes in the breast. Which of the following statements should the nurse make?

10 :
A nurse is caring for a client who is receiving methadone therapy as treatment for an opioid use disorder. Which of the following findings should indicate to the nurse that the client is experiencing the therapeutic effects of this medication?