A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

“If my stockings feel tight, I’ll just roll them down for a while.”

“I’ll put on my elastic stockings at the first sign of swelling.”

“When I sit down to watch television, I’ll be sure to put my feet up.”

“It is okay to cross my legs as long as it is less than one hour.”

Answer and Explanation

The Correct Answer is C

Choice A reason: Rolling down tight stockings creates a tourniquet effect, worsening venous insufficiency. Elevating feet improves circulation, making this incorrect, as it reflects a misunderstanding of compression therapy compared to the correct management taught by the nurse for venous insufficiency.

Choice B reason: Putting on stockings after swelling begins is less effective than wearing them preventatively. Elevating feet reduces edema, making this incorrect, as it shows partial understanding compared to the proactive elevation strategy indicating full comprehension of the nurse’s teaching.

Choice C reason: Elevating feet when sitting promotes venous return, reducing edema in venous insufficiency. This aligns with self-care education for the condition, making it the correct statement, as it demonstrates the client’s accurate understanding of the nurse’s teaching to manage lower extremity swelling.

Choice D reason: Crossing legs impairs venous return, exacerbating venous insufficiency, regardless of duration. Elevating feet is correct, making this incorrect, as it reflects a misconception about safe practices compared to the nurse’s teaching on managing venous insufficiency effectively.

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Correct Answer is ["A","B","D"]

Explanation

Choice A reason: A potassium level of 7.0 mEq/L risks lethal arrhythmias, necessitating cardiac monitoring. This aligns with hyperkalemia management, making it a correct priority action the nurse would plan to ensure the client’s safety and detect cardiac changes promptly.

Choice B reason: Notifying the provider is critical for a potassium level of 7.0 mEq/L, as urgent interventions like insulin or dialysis may be needed. This aligns with acute care protocols, making it a correct priority action for the nurse to address hyperkalemia.

Choice C reason: NPO status with ice chips is unrelated to hyperkalemia management, which focuses on lowering potassium. Cardiac monitoring is a priority, making this incorrect, as it’s not relevant to the nurse’s urgent actions for a client with severe hyperkalemia.

Choice D reason: Reviewing medications identifies potassium-containing or retaining drugs, preventing further elevation of 7.0 mEq/L. This aligns with hyperkalemia treatment, making it a correct priority action the nurse would plan to manage the client’s electrolyte imbalance effectively.

Choice E reason: Extra IV fluids (500 mL) may dilute potassium but risk fluid overload in acute kidney injury. Notifying the provider is more urgent, making this incorrect, as it’s not a priority compared to the nurse’s focus on immediate hyperkalemia interventions.

A. Client whose deep tendon reflexes have become hyperactive. B. Client who displays plantar flexion when the bottom of the foot is stroked. C. Client who consistently demonstrates decortication when stimulated. D. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 10.

Correct Answer is D

Explanation

Choice A reason: Hyperactive reflexes suggest neurological irritability but are less urgent than a GCS drop from 15 to 10, indicating deteriorating consciousness. This is incorrect, as it’s lower priority than the nurse’s focus on a client with a significant neurological decline.

Choice B reason: Plantar flexion (Babinski sign) may indicate neurological issues, but a GCS drop to 10 signals acute deterioration, requiring immediate attention. This is incorrect, as it’s less critical than the nurse’s priority to assess the client with a declining GCS.

Choice C reason: Decortication indicates severe brain injury but, if consistent, is less acute than a GCS drop from 15 to 10, suggesting rapid worsening. This is incorrect, as it’s not the nurse’s first priority compared to the client with acute neurological change.

Choice D reason: A GCS drop from 15 to 10 indicates a significant decline in consciousness, a neurological emergency requiring immediate assessment. This aligns with neurosurgical priorities, making it the correct client for the nurse to prioritize on the unit.

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A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse would plan which actions as a priority? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

The nurse has just received a report on a group of clients on the neurosurgical unit. Which client is the nurse’s first priority?

Correct Answer is D

Explanation

The nurse cares for a client with 0.9% sodium chloride infusing at 125 mL/h. 2 hours after the infusion was started, the client’s central venous pressure (CVP) reading is 16 cm H2O. It is MOST important for the nurse to take which action?

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A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? (Select all that apply)

The nurse monitoring a client receiving peritoneal dialysis notes that the client’s outflow is less than the inflow. Which actions would the nurse take? (Select all that apply)

A client with peripheral artery disease is suffering from ineffective tissue perfusion. Which of the following would be appropriate outcomes for this nursing diagnosis? (Select all that apply)

The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)