A nurse is assessing a client admitted with peripheral vascular disease.
Which of the following findings indicates a venous vascular disorder?
Edema of the ankle.
Hair loss distal to the client's calves.
Leg pain at rest.
An ulcer on the tip of a toe.
The Correct Answer is A
Edema, or swelling in the legs, is a common symptom of venous disease.
Hair loss distal to the client’s calves (choice B) is not a typical symptom of venous vascular disorder.
Leg pain at rest (choice C) can be a symptom of peripheral vascular disease but is not specific to venous vascular disorder.
An ulcer on the tip of a toe (choice D) can be a sign of arterial vascular disorder but is not specific to venous vascular disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse’s priority for immediate intervention is tachypnea, which is rapid breathing.
Tachypnea can be a sign of respiratory distress and requires immediate intervention.
Choice A is wrong because while a fever may indicate an infection, it is not the priority for immediate intervention.
Choice B is wrong because while blood-tinged secretions may indicate bleeding, it is not the priority for immediate intervention.
Choice D is wrong because while IV infiltration may cause discomfort and require attention, it is not the priority for immediate intervention.
Correct Answer is A
Explanation
The nurse’s priority assessment in the PACU (Post-Anesthesia Care Unit) should be the client’s respiratory status.
This is because the client is recovering from anesthesia and may have an altered respiratory function.
Choice B, assessing the surgical site, is not an answer because it is not the priority assessment for a client in the PACU.
Choice C, assessing the level of consciousness, is not an answer because it is not the priority assessment for a client in the PACU.
Choice D, assessing the pain level, is not an answer because it is not the priority assessment for a client in the PACU.
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