A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect?

Thickened toenails

Shiny, thin skin on the lower extremities

Dusky, red color of the feet when dangling

Pitting edema

Answer and Explanation

The Correct Answer is D

Choice A reason : Thickened toenails are often associated with fungal infections and are not a direct symptom of venous insufficiency. However, they can appear in patients with chronic venous insufficiency due to poor circulation that affects the health of the toenails.

Choice B reason : Shiny, thin skin on the lower extremities is more characteristic of arterial insufficiency, where there is a reduction in blood flow and oxygen to the tissues. In venous insufficiency, the skin may instead appear thickened and discolored due to stasis and buildup of hemosiderin from the breakdown of red blood cells.

Choice C reason : A dusky, red color of the feet when dangling can be a sign of dependent rubor, which is associated with arterial insufficiency. This occurs when there is a severe decrease in arterial blood flow to the lower extremities. Venous insufficiency may cause a different color change, typically a brownish discoloration due to hemosiderin deposition.

Choice D reason : Pitting edema is a hallmark sign of venous insufficiency. It occurs due to the accumulation of fluid in the tissues, which is a result of increased pressure in the veins. This pressure causes fluid to leak into the surrounding tissues, leading to swelling that retains an indentation when pressed.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason : Morphine is an opioid analgesic used to relieve severe pain and can be administered to patients with myocardial infarction to alleviate chest pain and anxiety. However, it is not the first medication given as it does not address the underlying cause of the myocardial infarction, which is the formation of a blood clot in the coronary arteries.

Choice B reason : Nitroglycerin is a nitrate that helps to dilate blood vessels and improve blood flow. It can be used to relieve chest pain in myocardial infarction, but similar to morphine, it is not the initial medication of choice. The priority is to prevent further blood clotting.

Choice C reason : Administered as soon as possible to inhibit platelet aggregation and reduce clot progression.

Choice D reason : When a myocardial infarction (MI) is suspected, the priority is to address tissue hypoxia and ensure adequate oxygenation to minimize myocardial damage. Administering oxygen helps increase oxygen availability to the ischemic heart tissue, reducing further damage.

A. Encourage the client to use guided imagery to relax. B. Elevate the head of the client's bed. C. Increase the client's fluid intake. D. Instruct the client to perform the Valsalva maneuver. E. Instruct the client to perform the Valsalva maneuver.

Correct Answer is C

Explanation

Choice A reason : Guided imagery is a relaxation technique that can help reduce stress and anxiety, but it does not directly address the physiological issues of dehydration and hypotension. While it may be beneficial as a complementary therapy, it is not the primary intervention for a patient suffering from these conditions.

Choice B reason : Elevating the head of the bed is generally recommended for patients who have difficulty breathing or to prevent aspiration, but it is not the standard care for hypotension. In fact, for a hypotensive patient, elevating the legs might be more beneficial to promote venous return to the heart⁹[^20^].

Choice C reason : Increasing fluid intake is the most direct and effective way to treat dehydration. When a patient is hypotensive, it often indicates a low blood volume, which can be improved by increasing fluid intake. This can be done orally if the patient is conscious and able to drink, or intravenously if they are not. The normal range for blood pressure is 90/60 mmHg to 120/80 mmHg, and maintaining adequate hydration helps to ensure blood pressure stays within this range⁸.

Choice D reason : The Valsalva maneuver is a technique used to potentially correct certain types of abnormal heart rhythms, particularly supraventricular tachycardia, and not for treating hypotension or dehydration. It involves increasing intrathoracic pressure by exhaling forcefully with a closed airway, which can have various effects on the cardiovascular system. However, it is not an appropriate intervention for a dehydrated, hypotensive patient⁹[^10^].

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who has a suspected myocardial infarction. Which of the following medications should the nurse plan to administer first?

Correct Answer is D

Explanation

A nurse is assisting in the plan of care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is caring for a client who asks why she is being prescribed aspirin 325 mg daily following a myocardial infarction. The nurse should instruct the client that aspirin is prescribed for clients who have coronary artery disease for which of the following effects?

A nurse is assisting with teaching a newly licensed nurse about heart sounds. Which of the following sounds is heard when the aortic and pulmonic valves close?

A nurse is caring for a client who has hypertension and is to start taking atenolol. The nurse should instruct the client to monitor for which of the following findings as an adverse effect of this medication?

A nurse is preparing to perform a 12-lead electrocardiogram (ECG). Which of the following instructions should the nurse provide to the client?

A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?

A nurse on a telemetry unit is reviewing the laboratory results for a client who has atrial fibrillation and is taking warfarin. Which of the following laboratory values should the nurse report to the provider?

A nurse is caring for a client who recently had surgery for the insertion of a permanent pacemaker. Which of the following prescriptions should the nurse question?

A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?