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
“Weight loss of.8 kg (4 Ib) in the past 24 hr.” Furosemide is a diuretic that decreases the pressure caused by excess fluid in the heart and lungs.
A weight loss of.8 kg (4 Ib) in the past 24 hr indicates that excess fluid is being removed from the body, which is a sign that the medication is effective.
Choice A is incorrect because adventitious breath sounds are a symptom of pulmonary edema, not an indication that the medication is effective.
Choice B is incorrect because furosemide has direct vasodilatory outcomes 2, which would decrease blood pressure, not elevate it.
Choice D is incorrect because there is no information found to support this statement.
Correct Answer is A
Explanation
The correct answer is A. Back pain.
Choice A reason: Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.
Choice C reason: Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.
Choice D reason: Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.
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