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1. A female client calls the nurse 3."Contact your health care provider right
at the clinic and reports that away to report this problem."
ever since the vein ligation and Rationale:
stripping procedure was per- A sensation of pins and needles or feel-
formed, she has been experi- ing as though the surgical limb is falling
encing a sensation as though asleep may indicate temporary or per-
the affected leg is falling manent nerve damage after surgery. The
asleep. The nurse should make saphenous vein and the saphenous nerve
which response to the client? run close together, and damage to the
1, "Apply warm packs to the nerve will produce paresthesias. Options 1,
leg." 2, and 4 are inaccurate responses. An alter-
2."Keep the leg elevated as native to surgery is endovenous ablation of
much as possible." the saphenous vein. Ablation involves the
3."Contact your health care insertion of a catheter that emits energy.
provider right away to report This causes collapse and sclerosis of the
this problem." vein. Potential complications include bruis-
4."This normally occurs after ing, tightness along the vein, recanalization
surgery and will subside when (reopening of the vein), and paresthesia.
the edema goes down." Endovenous ablation also may be done
in combination with saphenofemoral liga-
tion or phlebectomy. Transilluminated pow-
dered phlebectomy involves the use of a
powdered resector to destroy the varices
and then removes the pieces via aspiration.
2. An ambulatory care nurse mea- 1."It is important that I limit protein intake."
sures the blood pressure of a Rationale:
client and finds it to be 156/94 Obesity and sodium intake are modifiable
mm Hg. Which statement indi- risk factors for hypertension. These are of
cates the client needs addition- the utmost importance because they can
al education? be changed or modified by the individual
1."It is important that I limit pro- through a regular exercise program and
tein intake." careful monitoring of sodium intake. Protein
2."I need to maintain a regular intake has no relationship to hypertension.
exercise program."
3."I understand that I need to
avoid adding salt to foods."
4."It is important that I begin
, Cardiovascular NCLEX-RN
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reducing and then maintaining
weight."
3. A nurse identifies that a client 4.Serum potassium level of 2.8 mEq/L
is having occasional prema- Rationale:
ture ventricular contractions The nurse should check the client's serum
(PVCs) on the cardiac monitor. laboratory study results for hypokalemia.
The nurse reviews the client's The client may experience PVCs in the
laboratory results and deter- presence of hypokalemia, because this
mines that which result would electrolyte imbalance increases the electri-
be consistent with the observa- cal instability of the heart. The values noted
tion? in the remaining options are normal.
1.Serum sodium level of 145
mEq/L
2.Serum chloride level of 98
mEq/L
3.Serum calcium level of 10
mg/dL
4.Serum potassium level of 2.8
mEq/L
4. A client's total cholesterol lev- 3.The client is at high risk for cardiovas-
el is 344 mg/dL, low-density cular disease, and measures to modify all
lipoprotein cholesterol (LDL-C) identified risk factors should be taught.
level is 164 mg/dL, and Rationale:
high-density lipoprotein cho- In the absence of documented cardiovas-
lesterol (HDL-C) level is 30 cular disease, the desired goal is to have
mg/dL. Based on analysis of the total cholesterol level lower than 200
the data, how should the nurse mg/dL. A desired LDL-C level for all individ-
direct client teaching? uals is lower than 100 mg/dL, and a desir-
1.The client should maintain able HDL-C level is higher than 40 mg/dL.
the current dietary regimen but Because the client's levels are outside the
increase activity level. range for all three values to a significant
2.Results are inconclusive un- degree, the client is at high risk for devel-
less the triglyceride level is oping cardiovascular disease and requires
also screened, so teaching is teaching on risk factor reduction.
not indicated at this time.
3.The client is at high risk
for cardiovascular disease, and