The nurse assesses a client’s legs. Which assessment finding indicates arterial insufficiency? a. Full veins present in dependent extremity. Ankle discoloration and pitting edema Decrease or absent palpable pulses. Pain with activity but not while resting.
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The nurse assesses a client’s legs. Which assessment finding indicates arterial insufficiency? a. Full veins present in dependent extremity.
- Ankle discoloration and pitting edema
- Decrease or absent palpable pulses.
- Pain with activity but not while resting.
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- In addition to a cardiac glycoside and a diuretic, the provider prescribes an ACE inhibitor to treat the client's heart failure. The nurse should reinforce to the client that OTC medications can reduce the effectiveness of the ACEinhibitor. What otherinteractions with the ACEinhibitor should the nurse teach the client about?When administering any vasopressor during the treatment of shock, the nurse knows the assessment finding that best supports the goal of therapy is: a. Constriction of vessels to maintain BP b. Dilating vessels to improve tissue oxygenation c. Maintaining a MAP of, or greater than 65 mm Hg d. Increased urine output to 50 mL/hrIn the Emergency room a 50 year-old male is rushed due to hypertension. After a few minutes of intervention, his blood pressure stabilizes and is back to normal. At present he has a complaint of pain in his right big toe. Upon assessment, the nurse documents the following presentations: When the right toe is touched the patient winces in pain. The site is red and warm when touched. According to the patient, movement of the toe hurts a lot. Pain also becomes severe at night. He rates his pain at 8 from a pain scale of 0 – 10. A medical diagnosis of gout was considered. Formulate a Nursing Care Plan using an Actual Nursing Diagnosis. NURSING EVALUATION
- In the Emergency room a 50 year-old male is rushed due to hypertension. After a few minutes of intervention, his blood pressure stabilizes and is back to normal. At present he has a complaint of pain in his right big toe. Upon assessment, the nurse documents the following presentations: When the right toe is touched the patient winces in pain. The site is red and warm when touched. According to the patient, movement of the toe hurts a lot. Pain also becomes severe at night. He rates his pain at 8 from a pain scale of 0 – 10. A medical diagnosis of gout was considered. Formulate a Nursing Care Plan using an Actual Nursing Diagnosis. NURSING DIAGNOSIS NURSING GOAL NURSING INTERVENTIONS (with rationale) NURSING EVALUATIONA client is prescribed furosemide and digoxin to manage their symptoms associated with heart failure. The nurse understands which of following is true when taking these medications together? Furosemide can cause a loss of potassium, creating a higher risk of digoxin-induced dysrhythmias Furosemide can cause an excess retention of potassium, creating a higher risk of digoxin-induced dysrhythmias. Furosemide can promote loss of potassium and thereby decrease the risk of digoxin-induced dysrhythmias. There is no concern for the concomitant use of these two medications.For the management of hypertensive crisis, the nurse is aware that the initial goal of treatment includes: a. Decreasing the mean arterial pressure (MAP) by no more than 20-25% b. Decreasing the diastolic blood pressure below 100 as soon as possible c. The use of ACE inhibitors and diuretics to lower blood pressure quickly d. Decreasing the mean arterial pressure (MAP) to 80-100 mmHg within 30 minutes
- The nurse is caring for a client who has suffered a femur fracture (lower extremity). To assess the neurovascular/circulation and status of the affected extremity, which pulse would the nurse palpate ? Dorsalis Pedis Temporal Brachial CarotidAn older client is receiving an IV of 0.9% Normal Saline solution at 75 mL/hour. Which finding indicates to the practical nurse that the client may be developing a complication from this therapy? A Episodes of vertigo and loss of balance.B Fatigue and breathlessness upon exertion. C Apical pulse rate of 64 beats/minute. D Average 24-hour urinary output of 1,400 mL.The RN has administered the following medications to the client with heart failure; metoprolol, lisinopril, spironolactone. What data collection and assessment parameters should the nurse perform prior to the administration of these medications?
- The nurse takes an initial blood pressure of a client and notes it to be 152/92 . Which of the following actions by the nurse is incorrect? Tell the client he or she has hypertension and recommend they get treatment Recheck the blood pressure after a period of rest Assess for factors that may have elevated the blood pressure prior to the measurement Ask about a history of high blood pressure and any medications takenThe nurse asks you to obtain a complete set of vital signs for one of the persons to whom you are assigned. Upon measurement, you determine the following: temperature 38.6°C (101.5°F), heart rate 104 beats/min, respiratory rate 22 breaths/min, and blood pressure 90/60 mm Hg. Which of these vital signs are of concern? What subjective data could be stated by the client? What is your first action after collecting these vital signs?The HCP tells the nurse that the patient'»heart rate is 114. Based on yourknowledge regarding assessing a pulse,which of the following terms isappropriate? This is the pulse deficit This is the pulse volume The patient is Bradycardic. The patient is Tachycardic.