The correct answer number and rationale for why it is the correct answer are given in boldface type.
Rationales for why the other possible answer options are incorrect also are given, but they are not in bold-face type.
1. 1. The client has an elevated blood pressure, but it is not life threatening; therefore, the client does not need to be seen first.
2. The client with a DVT would be expected to be complaining of calf pain; therefore, this client would not be seen first.
3. The client with peripheral vascular disease would be expected to have intermittent clau-dication; therefore, this client would not be seen first.
4. The client with a triple AAA who has a low back pain could have a leak, which could be life threatening; therefore, this client should be assessed first.
2. 1. Increased hair loss occurs due to decreased oxygen to the lower extremities, but this is not life threatening; therefore, this information would not warrant immediate intervention.
2. The client with arterial occlusive disease would be expected to have an absent dorsal pedal pulse; therefore, this would not warrant immediate intervention.
3. Numbness, tingling, and inability to move his or her toes would warrant intervention by the nurse. This indicates no arterial blood flow to the extremities.
4. The client hangs his or her legs off the bed to help increase arterial oxygen blood flow to the lower extremities. This would not warrant immediate intervention.
3. 1. JC cannot delegate assessment, teaching, evalu-ation, medications, or an unstable client to the UAP. Checking the pedal pulse is assessment.
2. The client who is 4 hours postoperative leg surgery would not be able to ambulate down the hall. The client will be on bed rest for at least 24 hours.
3. JC cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP.
4. The leg should be elevated to help de-crease edema secondary to surgery and this can be delegated to a UAP.
4. 3 and 4 are correct.
1. A daily aspirin is recommended as an antico-agulant to clients with atherosclerosis.
2. A low-fat, low-cholesterol diet is recom-mended to help decrease plaque formation in the vessels.
3. Sedentary life style is a “couch potato”
lifestyle, which is not recommended for clients with atherosclerosis.
4. The client should eat foods high in fiber to help decrease his or her cholesterol level.
5. Walking is an excellent isotonic exercise, which is recommended to help lose weight, de-velop collateral circulation, and decrease stress.
5. 1. BN should auscultate the bowel sounds, but BN should first assess the client’s surgical in-cision, since the client is 2 days postoperative.
2. BN should first assess the surgical dress-ing to assess for bleeddress-ing or any type of drainage, then continue with the rest of the assessment, including bowel sounds, vital signs, and IV therapy.
3. The nurse should assess first, since it is the first part of the nursing process when the client is not in distress.
4. Monitoring the intravenous therapy should be done by BN, but assessment is the first intervention.
6. 1. The client should not lift more than 5 pounds;
doing so might cause the surgical incision to have dishensence. This statement indicates the client understands the teaching.
2. The number one factor for developing ath -erosclerosis and increased blood pressure is smoking cigarettes; therefore, the client must quit. This statement indicates the client un-derstands the teaching.
3. A truss is a kind of surgical appliance used for clients with a hernia. It provides sup-port for the herniated area using a pad and belt arrangement to hold it in the cor-rect position. This client would not be prescribed a truss; therefore, the client needs more discharge teaching.
4. The client should notify the healthcare provider if there is an elevated temperature because this indicates that the client has a postoperative infection. This statement indi-cates the client understands the teaching.
7. 1. PN would expect the client to have pain in the surgical area and, though this client’s pain needs to be assessed, it would not be prior to a client in renal failure.
2. The 3+ posterior tibial pulse indicates the blood supply to the foot is adequate and would not require the client to be seen first by PN.
3. The client is going into renal failure (should be 30 mL/hr), which is a poten-tially life-threatening complication of triple AAA surgery; therefore, this client must be assessed first.
4. The client complaint needs to be addressed, but not prior to a physiological potentially life-threatening complication.
8. Answer: 16 mL/hour.To determine the rate, the test taker must first determine how many units are in each mL of fluid; 25,000 divided by 500 = 50 units of heparin in each mL of fluid, and 50 divided into 100 = 2, 18-2 = 16.
9. 1. The client should elevate the lower extremi-ties to help decrease the edema and help the unoxgenated blood go up the inferior cava.
2. Massaging the legs would not warrant inter-vention for this client; it would be inappro-priate for a client with deep vein thrombosis.
Varicose veins will not dislodge a clot.
3. The client with varicose veins should not be on bed rest. The client should have bathroom privileges and up ad lib.
4. The UAP can calculate the client’s I&O, not evaluate the I&O.
10. 1. Hospice is for a client whose healthcare provider determines the client has less than 6 months to live. This client does not have this diagnosis.
2. The home health nurse is an appropriate referral for this client. The client’s home should be assessed to determine if the client needs assistance in the home.
3. The physical therapist addresses gait training and transferring.
4. Cardiac rehabilitation helps clients who have had myocardial infarctions, cardiac bypass surgery, or congestive heart failure recover.
SCENARIO ANSWERS
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