the nurse is teaching the client with peripheral vascular disease which intervention should the nurse discuss with the client
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 4

1. The client with peripheral vascular disease is being taught by the nurse. Which interventions should the nurse discuss with the client?

Correct answer: D

Rationale: The correct interventions for a client with peripheral vascular disease include keeping the area between the toes dry and wearing comfortable, well-fitting shoes. Choice A is correct as moisture between the toes can lead to skin breakdown and infection. Choice B is also correct as proper footwear helps prevent injury and promotes circulation. Choice C, cutting toenails straight across, is incorrect for peripheral vascular disease clients as cutting them in an arch can reduce the risk of ingrown toenails, which is important for clients with diabetes to prevent complications. Therefore, choices A and B are the most appropriate interventions for the client with peripheral vascular disease.

2. What is the FIRST step in providing health care for a patient?

Correct answer: B

Rationale: The correct first step in providing health care for a patient is to determine the needs of the patient. Understanding the patient's requirements, concerns, and medical history is crucial before proceeding with any further steps. Option A, 'Obtain and interpret vital signs,' may be necessary but typically follows assessing the patient's needs. Option C, 'Develop a plan of care,' comes after identifying the patient's needs. Option D, 'Obtain lab work and x-rays,' is usually done based on the patient's needs and the developed plan of care, making it a later step in the process.

3. What is established when threats to air resources prevent evacuation by air from forward units?

Correct answer: C

Rationale: Ambulance exchange points are set up when threats to air resources make it impossible to evacuate by air from forward units. These points serve as locations where patients can be transferred from ambulances to aircraft for further evacuation. Area support medical battalions (Choice A) are not directly related to this scenario, as they provide medical support to larger areas. TOE units (Choice B) refer to tables of organization and equipment, not specific to this situation. Field hospitals (Choice D) are more permanent facilities for treating patients and are not specifically for transferring patients under threats to air resources.

4. In assessing the client's chest, which position best shows chest expansion as well as its movements?

Correct answer: A

Rationale: The correct answer is A: Sitting. When the client is seated, their chest is in an optimal position for observing the full range of chest expansion during breathing. This position allows for easy visualization of chest movements and expansion as the client breathes in and out, providing a comprehensive assessment of respiratory function. Choice B, Prone, is incorrect as lying face down would not provide a clear view of chest expansion. Choice C, Sidelying, is also incorrect as this position may limit the visibility of chest movements. Choice D, Supine, is not the best position for assessing chest expansion as it may not offer a clear observation of chest movements during breathing.

5. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

Correct answer: A

Rationale: A consultation with a Rapid Response Team (RRT) is most appropriate for the 45-year-old client described in Choice A. This client is 2 years post kidney transplant, presenting with no urine output for 6 hours, a temperature of 101.4°F, heart rate of 98 beats per minute, respirations of 20 breaths per minute, and a blood pressure of 88/72 mm Hg, along with restlessness. These clinical signs are indicative of possible acute renal failure and sepsis, requiring immediate intervention by the rapid response team. Choices B, C, and D do not present the same level of urgency and severity of symptoms as the client in Choice A, making them less appropriate for consultation with the RRT.

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