a client is admitted to the hospital with a venous stasis leg ulcer the nurse inspects the ulcer expecting to note which observation
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1. A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation?

Correct answer: D

Rationale: When assessing a venous stasis leg ulcer, the nurse should expect to note a brownish or 'brawny' appearance. This discoloration is often due to hemosiderin deposits. The correct answer is not A because venous stasis ulcers typically do not have a pale-colored base. Choice B is incorrect as venous stasis ulcers usually have irregular, shallow edges, not deep and even edges. Choice C is incorrect as venous stasis ulcers often have excess granulation tissue, not little granulation tissue. Recognizing the brownish or 'brawny' appearance is crucial for accurate diagnosis and appropriate treatment of venous stasis leg ulcers.

2. A client with a history of myocardial infarction (MI) is being discharged with a prescription for nitroglycerin sublingual tablets. Which instruction should the nurse reinforce?

Correct answer: A

Rationale: The correct answer is A. Nitroglycerin tablets are light and moisture-sensitive, so they should be stored in a cool, dry place away from light to maintain their effectiveness. Option B advises taking a tablet every 5 minutes, which may lead to overdose as this frequency is too high. Option C emphasizes the correct administration route for sublingual tablets. Option D is incorrect as water is not needed for the tablets to take effect.

3. When assisting a hospitalized client newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu, which meal should the nurse encourage the client to select?

Correct answer: D

Rationale: The correct choice is D: Fresh strawberries, steamed vegetables, and baked fish. This meal is low in saturated fats and cholesterol, which is suitable for a client with CAD. It aligns with dietary recommendations to support heart health and manage CAD. Choices A, B, and C are less appropriate as they contain higher levels of saturated fats and cholesterol, which are not ideal for individuals with CAD.

4. The client is receiving anticoagulant therapy for atrial fibrillation. Which laboratory test should be monitored to determine the effectiveness of the therapy?

Correct answer: A

Rationale: Prothrombin time (PT) and international normalized ratio (INR) are essential laboratory tests to monitor the effectiveness of anticoagulant therapy in clients with atrial fibrillation. These tests help ensure that the client is within the therapeutic range and are commonly used to assess the clotting ability of the blood. Monitoring PT and INR levels allows healthcare providers to adjust anticoagulant dosages as needed to prevent complications such as bleeding or thrombosis. Activated partial thromboplastin time (aPTT) is more commonly used to monitor heparin therapy, not anticoagulant therapy for atrial fibrillation. Platelet count assesses the number of platelets in the blood and is not a direct indicator of anticoagulant therapy effectiveness. Erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation and is not used to monitor anticoagulant therapy.

5. A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the LPN/LVN expect to assist with first?

Correct answer: B

Rationale: In a client with pulmonary edema, placing them in a high Fowler's position is the priority intervention. This position helps to improve ventilation and oxygenation by decreasing venous return, reducing the workload on the heart, and facilitating fluid redistribution from the lungs. It is crucial to optimize respiratory function and oxygenation before considering other interventions like administering medications, preparing for intubation, or inserting a urinary catheter. Administering a diuretic, preparing for intubation, or inserting a urinary catheter may be necessary but should follow the priority of improving oxygenation through positioning.

Similar Questions

An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked, and his eyeballs appear sunken into his head. Which nursing intervention is indicated?
The LPN/LVN is reinforcing discharge instructions to a client who has been prescribed nitroglycerin sublingual tablets for angina. Which statement by the client indicates a need for further teaching?
The client with a diagnosis of heart failure is receiving furosemide (Lasix). Which laboratory value is most important for the nurse to monitor?
The healthcare professional is assisting in the care of a client diagnosed with heart failure. The client is receiving furosemide (Lasix). Which laboratory value should the healthcare professional monitor most closely?
The client with heart failure is receiving digoxin (Lanoxin). The nurse should monitor the client for which sign of digoxin toxicity?

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