Giddens Concepts for Nursing Practice Test Bank

Questions 14

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Giddens Concepts for Nursing Practice Test Bank Questions

Question 1 of 5

A client admitted with chronic venous insufficiency has an infected wound of the left lower extremity. Which clinical manifestations does the nurse anticipate during the client's assessment? Select all that apply.

Correct Answer: A

Rationale: 1. Pulses absent in the extremity with the wound (Option A): In chronic venous insufficiency, damaged valves in the veins result in blood pooling in the lower extremities. This can lead to decreased arterial perfusion and impaired circulation, causing weakened or absent pulses in the affected extremity.

Question 2 of 5

A client admitted with chronic venous insufficiency has an infected wound of the left lower extremity. Which clinical manifestations does the nurse anticipate during the client's assessment? Select all that apply.

Correct Answer: A

Rationale: 1. Pulses absent in the extremity with the wound (Option A): In chronic venous insufficiency, damaged valves in the veins result in blood pooling in the lower extremities. This can lead to decreased arterial perfusion and impaired circulation, causing weakened or absent pulses in the affected extremity.

Question 3 of 5

Following surgery, a patient has not voided for 12 hours. What assessment should the nurse make?

Correct Answer: C

Rationale: Following surgery, a patient not voiding for 12 hours raises concerns for urinary retention, especially if the patient was catheterized during the surgical procedure. With urinary retention, the bladder can become distended and palpating for bladder distention can help determine if the patient is experiencing this issue. If the bladder is distended, interventions may be needed to address the urinary retention to prevent complications such as urinary tract infection or bladder distention-related discomfort. The other assessment options (percuting for gastric tympany, auscultating for bowel sounds, inspecting for edema of the urethra) are not as relevant in assessing a patient's urinary status post-surgery.

Question 4 of 5

The nurse has identified Ineffective Peripheral Tissue Perfusion as a nursing diagnosis for a client with disseminated intravascular coagulation (DIC). What intervention would be appropriate for the client?

Correct Answer: B

Rationale: In the context of Ineffective Peripheral Tissue Perfusion in a client with disseminated intravascular coagulation (DIC), administering oxygen is the most appropriate intervention. DIC is a serious condition characterized by widespread clotting in small blood vessels throughout the body, leading to tissue ischemia and inadequate perfusion. Administering oxygen can support tissue oxygenation and improve perfusion to the peripheral tissues, helping to alleviate the effects of decreased blood flow and oxygen delivery caused by DIC. Oxygen therapy can help optimize oxygen levels in the blood and tissues, promoting better tissue perfusion and overall patient outcomes. Monitoring oxygen saturation and ensuring adequate oxygen delivery are crucial aspects of managing tissue perfusion in clients with DIC.

Question 5 of 5

A client with preeclampsia begins to demonstrate manifestations of seizure activity. Which intervention by the nurse is most likely to protect the client and fetus from injury?

Correct Answer: B

Rationale: Placing the client on the left side and protecting the airway is the most appropriate intervention to protect the client and the fetus from injury during a seizure. This position helps to prevent aspiration of vomitus and maintains an open airway. Placing the client on the left side also enhances maternal and fetal perfusion by reducing pressure on the vena cava, improving blood flow to the placenta, and decreasing the risk of supine hypotensive syndrome. Elevating the client's legs (Option A) and placing the client in the supine position (Option C) are contraindicated as they may worsen the client's condition in the context of preeclampsia and seizure activity. Elevating the head of the bed (Option D) does not address the immediate need to protect the airway and maintain proper positioning during a seizure.

Similar Questions

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