3. "Contact your health care provider right away to report
this problem."
Rationale:
A sensation of pins and needles or feeling as though the
A female client calls the nurse at the clinic and reports surgical limb is falling asleep may indicate temporary or
that ever since the vein ligation and stripping procedure permanent nerve damage after surgery. The saphenous
was performed, she has been experiencing a sensation as vein and the saphenous nerve run close together, and
though the attected leg is falling asleep. The nurse should damage to the nerve will produce paresthesias. Options
make which response to the client? 1, 2, and 4 are inaccurate responses. An alternative to
1, "Apply warm packs to the leg." surgery is endovenous ablation of the saphenous vein.
2. "Keep the leg elevated as much as possible." Ablation involves the insertion of a catheter that emits
3. "Contact your health care provider right away to report energy. This causes collapse and sclerosis of the vein.
this problem." Potential complications include bruising, tightness along
4. "This normally occurs after surgery and will subside the vein, recanalization (reopening of the vein), and pares-
when the edema goes down." thesia. Endovenous ablation also may be done in com-
bination with saphenofemoral ligation or phlebectomy.
Transilluminated powdered phlebectomy involves the use
of a powdered resector to destroy the varices and then
removes the pieces via aspiration.
An ambulatory care nurse measures the blood pressure of 1. "It is important that I limit protein intake."
a client and finds it to be 156/94 mm Hg. Which statement Rationale:
indicates the client needs additional education? Obesity and sodium intake are modifiable risk factors for
1. "It is important that I limit protein intake." hypertension. These are of the utmost importance be-
2. "I need to maintain a regular exercise program." cause they can be changed or modified by the individual
3. "I understand that I need to avoid adding salt to foods." through a regular exercise program and careful monitor-
4. "It is important that I begin reducing and then maintain- ing of sodium intake. Protein intake has no relationship to
ing weight." hypertension.
A nurse identifies that a client is having occasional prema-
4. Serum potassium level of 2.8 mEq/L
ture ventricular contractions (PVCs) on the cardiac moni-
Rationale:
tor. The nurse reviews the client's laboratory results and
The nurse should check the client's serum laboratory study
determines that which result would be consistent with the
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, Cardiovascular NCLEX-RN Test Questions with Answers Rated A
observation?
results for hypokalemia. The client may experience PVCs
1. Serum sodium level of 145 mEq/L
in the presence of hypokalemia, because this electrolyte
2. Serum chloride level of 98 mEq/L
imbalance increases the electrical instability of the heart.
3. Serum calcium level of 10 mg/dL
The values noted in the remaining options are normal.
4. Serum potassium level of 2.8 mEq/L
A client's total cholesterol level is 344 mg/dL, low-density
lipoprotein cholesterol (LDL-C) level is 164 mg/dL, and
3.The client is at high risk for cardiovascular disease, and
high-density lipoprotein cholesterol (HDL-C) level is 30
measures to modify all identified risk factors should be
mg/dL. Based on analysis of the data, how should the
taught.
nurse direct client teaching?
Rationale:
1. The client should maintain the current dietary regimen
In the absence of documented cardiovascular disease, the
but increase activity level.
desired goal is to have the total cholesterol level lower than
2. Results are inconclusive unless the triglyceride level is
200 mg/dL. A desired LDL-C level for all individuals is low-
also screened, so teaching is not indicated at this time.
er than 100 mg/dL, and a desirable HDL-C level is higher
3. The client is at high risk for cardiovascular disease, and
than 40 mg/dL. Because the client's levels are outside the
measures to modify all identified risk factors should be
range for all three values to a significant degree, the client
taught.
is at high risk for developing cardiovascular disease and
4. The client is at low risk for cardiovascular disease, so
requires teaching on risk factor reduction.
the client should be encouraged to continue to follow the
current regimen.
The nurse is concerned about the adequacy of peripheral 2. Cover the legs lightly when sitting in a chair.
tissue perfusion in the post-cardiac surgery client. Which Rationale:
action should the nurse include within the plan of care for Covering the legs with a light blanket during sitting pro-
this client? motes warmth and vasodilation of the leg vessels. The
1. Use the knee-gatch on the bed. nurse plans postoperative measures to prevent venous
2. Cover the legs lightly when sitting in a chair. stasis. These include applying elastic stockings or leg
3. Encourage the client to cross legs when sitting in a wraps, use of pneumatic compression boots, and dis-
chair. couraging leg-crossing. Clients should be encouraged to
4. Provide pillows for the client to place under the knees as perform passive and active range of motion exercises. The
desired. knee gatch on the bed and pillows under the knees should
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