A nurse is checking the skin of a client who has chronic venous insufficiency.
Which of the following findings should the nurse identify as a venous stasis ulcer?

Red scaly patches with raised edges.

Round lesions with irregular borders.

Wounds with darkened pigmentation and drainage.

Circular areas with pale centers.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Red scaly patches with raised edges are characteristic of skin conditions like psoriasis or eczema, not venous stasis ulcers, which result from chronic venous insufficiency.

Choice B rationale

Round lesions with irregular borders are commonly seen in arterial ulcers. They result from ischemia rather than chronic venous insufficiency and differ in appearance from venous stasis ulcers.

Choice C rationale

Wounds with darkened pigmentation and drainage are hallmarks of venous stasis ulcers. Chronic venous insufficiency causes venous hypertension, leading to hemosiderin deposition, pigmentation, and wound development.

Choice D rationale

Circular areas with pale centers are associated with conditions like erythema multiforme or arterial issues, not with venous stasis ulcers arising from venous insufficiency.

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Correct Answer is A

Explanation

Choice A rationale

Requesting the client to be NPO is appropriate as the first step in response to symptoms like hypoactive bowel sounds and abdominal pain following surgery. These findings could indicate potential ileus or obstruction, and keeping the client NPO helps prevent further gastrointestinal complications while awaiting evaluation.

Choice B rationale

Administering a glycerin suppository can relieve constipation by stimulating rectal evacuation. However, it may not be appropriate without further evaluation, particularly in a postoperative client, as bowel obstruction or ileus must be ruled out before initiating bowel stimulants.

Choice C rationale

Offering an analgesic can help manage abdominal pain. However, it does not address the underlying cause of the hypoactive bowel sounds and cramping pain, which require further evaluation. Symptom management should not precede diagnostic assessment.

Choice D rationale

Ambulating the client may promote peristalsis and prevent complications such as blood clots. However, in the context of hypoactive bowel sounds and abdominal pain, further diagnostic evaluation is necessary before encouraging activity to avoid exacerbating a possible obstruction or ileus. .

A. The client has inspiratory stridor. B. The client reports a sore throat. C. The client's temperature is 38.6°C (101.4°F). D. The client's sputum has streaks of blood.

Correct Answer is A

Explanation

Choice A rationale

Inspiratory stridor reflects airway obstruction, potentially life-threatening following bronchoscopy. Causes include vocal cord edema or laryngospasm. Prompt intervention ensures airway patency and oxygenation. Audible stridor indicates urgent escalation.

Choice B rationale

Sore throat is anticipated due to irritation from the bronchoscope. This resolves without treatment, differentiating it from alarming symptoms like respiratory difficulty.

Choice C rationale

Post-bronchoscopy fever is common due to airway manipulation. Low-grade fever under 38.6°C does not necessitate urgent evaluation unless persistent or accompanied by other symptoms.

Choice D rationale

Bloody sputum results from mucosal trauma during the procedure. Minimal streaking is benign and resolves spontaneously. It does not indicate complications. .

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A nurse is checking the skin of a client who has chronic venous insufficiency.Which of the following findings should the nurse identify as a venous stasis ulcer?

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A nurse is checking the skin of a client who has chronic venous insufficiency.
Which of the following findings should the nurse identify as a venous stasis ulcer?