The client’s chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

Complaints of muscle cramps with exercise

Pedal pulses are +1 bilaterally

Complaints of burning pain during the night

Tissue that is blackened on the great toe

Answer and Explanation

The Correct Answer is C

Choice A rationale

Complaints of muscle cramps with exercise. While muscle cramps with exercise can be a symptom of peripheral arterial disease (PAD), they are more commonly associated with the earlier stages of the disease, known as intermittent claudication.

Choice B rationale

Pedal pulses are +1 bilaterally. Reduced or absent pedal pulses can be a sign of PAD, but a finding of +1 pedal pulses does not necessarily correlate with stage III of the disease.

Choice C rationale

Complaints of burning pain during the night. Stage III PAD, also known as critical limb ischemia, is characterized by more severe symptoms, including discomfort or pain in the feet or toes, even while at rest. Symptoms tend to worsen at night.

Choice D rationale

Tissue that is blackened on the great toe. This is a sign of gangrene, which is a severe and potentially life-threatening complication of PAD2. However, it is not a typical finding in stage III PAD, and would more likely be seen in the most advanced stage of the disease.

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Correct Answer is C

Explanation

Choice A rationale

While it might seem that smaller doses of both drugs could be used when they are prescribed together, this is not the primary reason for using heparin and warfarin together. Both drugs have different mechanisms of action and are used for their unique therapeutic effects.

Choice B rationale

The combination of heparin and warfarin does not facilitate thrombolysis more quickly. Thrombolysis is the process of breaking down clots, and while these medications can prevent the formation of new clots, they do not actively break down existing ones.

Choice C rationale

Heparin and warfarin are often used together in the treatment of thrombophlebitis because they provide different benefits. Heparin acts quickly to prevent further clotting and allows the body to naturally break down existing clots. Warfarin, on the other hand, takes several days to become effective. Therefore, heparin is used to provide immediate anticoagulation until the warfarin becomes effective.

Choice D rationale

While it’s true that the combination of heparin and warfarin provides immediate anticoagulation, this is primarily due to the action of heparin. Warfarin takes several days to become effective, so it does not contribute to the immediate anticoagulant effect.

A. People with Type 1 diabetes have little or none of their own insulin that can be released. B. People with Type 1 diabetes would need so much of an oral antihyperglycemic agent that it would cost too much. C. People with Type 1 diabetes have resistance to their endogenous insulin. D. People with Type 1 diabetes would have more episodes of hypoglycemia with oral antihyperglycemic agents.

Correct Answer is A

Explanation

Choice A rationale

People with Type 1 diabetes have little or no insulin that can be released. This is because their pancreatic β-cells, which produce insulin, are destroyed by an autoimmune process. Without insulin, glucose cannot be taken up into cells to be used for energy. Oral antihyperglycemic agents work by increasing the release of insulin or increasing the body’s sensitivity to insulin, so they are not effective in Type 1 diabetes where there is an absolute insulin deficiency.

Choice B rationale

The cost of oral antihyperglycemic agents is not the primary reason they are not used in Type 1 diabetes. The main issue is the lack of insulin production, which these medications cannot address.

Choice C rationale

People with Type 1 diabetes do not typically have resistance to their endogenous insulin. Insulin resistance is more commonly associated with Type 2 diabetes.

Choice D rationale

While hypoglycemia can occur with the use of some antihyperglycemic agents, this is not the primary reason these medications are not used in Type 1 diabetes. The main issue is the absolute deficiency of insulin.

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The client’s chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving heparin sodium 1000 units per hour via an infusion and warfarin sodium 2.5 mg PO for thrombophlebitis in the left leg. The nurse educates the client that heparin and warfarin are prescribed together because:

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is explaining to a patient why oral antihyperglycemic agents are not effective in Type 1 diabetes. What is the reason?

Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is aware that the diagnostic level of a fasting blood glucose for a client with diabetes is:

A nurse is caring for a client with a heart murmur due to mitral valve disease. Where would the nurse hear the murmur the loudest?

A patient diagnosed with peripheral arterial disease is being educated about the benefits of walking for exercise. What information should the nurse emphasize?

A patient diagnosed with Type 1 diabetes reports a blood glucose level of 210 mg/dL and symptoms of a sore throat, cough, and fever. What advice should the nurse give to the patient?

A patient receives 20 units of Isophane Insulin Suspension (NPH) Insulin at 07:30. At what time are signs of hypoglycemia most likely to occur?

A client undergoing screening for diabetes has a fasting plasma glucose level of 118 mg/dL. What should the nurse plan to educate the client about?

The client has been receiving vancomycin 1 gram IV every 12 hours for 2 days. What nursing actions are appropriate when administering this medication? (Select all that apply)

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