The nurse has been pulled from a medical unit to work on the vascular unit for the shift. Which client should the charge nurse assign to the medical unit nurse?

The client newly diagnosed with chronic venous insufficiency who needs teaching.

The client with the femoral-popliteal bypass who has paraesthesia of the foot.

The client with varicose veins who is reporting deep, aching pain in the legs.

The client with an abdominal aortic aneurysm who is reporting low back pain.

Answer and Explanation

Correct Answer : B,D

Peripheral arterial disease and vascular surgical conditions require urgent recognition of ischemic compromise, graft patency monitoring, and aneurysmal rupture risk due to impaired tissue perfusion, potential neurovascular deficit, and high risk of rapid clinical deterioration in vascular surgery patients.

Rationale:

A. Newly diagnosed chronic venous insufficiency requiring teaching is a stable, non-urgent condition. This involves venous valve incompetence leading to edema and skin changes. It is appropriate for teaching but not priority assignment. It does not require specialized vascular nursing judgment or acute monitoring.

B. Femoral-popliteal bypass with paraesthesia indicates possible acute graft occlusion or neurovascular ischemia. This is a postoperative vascular emergency requiring immediate assessment of limb perfusion. The medical unit nurse must recognize deterioration requiring urgent intervention and possible surgical notification.

C. Varicose veins with deep aching pain represents chronic venous disorder. This condition involves venous hypertension and is typically managed conservatively. Although symptomatic, it is not immediately life-threatening. It does not require specialized vascular postoperative surveillance or acute monitoring interventions.

D. Abdominal aortic aneurysm with low back pain suggests possible impending rupture. This is a surgical emergency due to risk of hemorrhage and hemodynamic collapse. Immediate monitoring and rapid escalation are required, making it appropriate for assignment to a nurse capable of recognizing instability.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Autonomic dysreflexia is a life-threatening neurological emergency occurring in spinal cord injuries at T-6 or above. It involves uninhibited sympathetic discharge triggered by noxious stimuli, causing extreme hypertension and potential cerebral hemorrhage. Immediate nursing intervention focuses on elevating the head and removing the triggering stimulus, such as a distended bladder.

Rationale:

A. This client is the priority due to the risk of status epilepticus or stroke from hypertensive crisis. Autonomic dysreflexia requires immediate vasodilation and assessment of the urinary or bowel systems. The nurse must act fast to prevent permanent neurological damage or sudden cardiovascular collapse.

B. Huntington's disease involves progressive neurodegeneration characterized by chorea, which are involuntary, jerky movements. While these symptoms are distressing and increase metabolic demands, they are expected findings in the middle stages of the disease. This client does not require immediate, life-saving stabilization over others.

C. Guillain-Barre syndrome involves demyelination causing ascending weakness, which is currently only at the knees. While the nurse must monitor for respiratory failure, the paralysis has not yet reached the diaphragm or intercostal muscles. This client is stable but requires frequent neurological checks throughout the shift.

D. The "pill-rolling" tremor is a classic, rhythmic resting tremor associated with dopamine depletion in the basal ganglia. It is a hallmark sign of Parkinson's disease and does not indicate acute physiological distress. This client’s needs are chronic in nature and do not take priority over emergency conditions.

Correct Answer is ["200"]

Explanation

Step 1: Identify total volume and time
Total volume = 100 mL, Time = 30 minutes = 0.5 hours

Step 2: Use the formula
mL/hour = Total volume ÷ Time (in hours)

Step 3: Insert values
= 100 ÷ 0.5

Step 4: Calculate
= 200 mL/hour

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The nurse has been pulled from a medical unit to work on the vascular unit for the shift. Which client should the charge nurse assign to the medical unit nurse?

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Naxlex Comprehensive Predictor Exams

The nurse has just received the shift report. Which client should the nurse assess first?

Correct Answer is A

Explanation

Correct Answer is ["200"]

Explanation

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