a 50 year old female is in the hospital with peripheral artery disease in the nursing care plan the nurse lists the following nursing diagnosis ineffe
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HESI LPN

PN Exit Exam 2023 Quizlet

1. A 50-year-old female is in the hospital with peripheral artery disease. In the nursing care plan, the nurse lists the following nursing diagnosis: Ineffective tissue perfusion: peripheral related to venous stasis. Which of the following would not be an appropriate nursing action to list in the implementation of this diagnosis?

Correct answer: A

Rationale: Keeping the client’s extremities cold would worsen perfusion issues and is not recommended. In peripheral artery disease, maintaining warmth is crucial to promote vasodilation and improve blood flow. Checking peripheral pulses for strength and symmetry, keeping the client's legs elevated to reduce venous stasis, and monitoring for constrictions that may impair circulation are appropriate nursing actions to enhance tissue perfusion in this case. Thus, option A is incorrect as it would hinder perfusion in the affected extremities.

2. A client post-thoracotomy is complaining of severe pain with deep breathing and coughing. What should the nurse encourage the client to do to manage the pain and prevent respiratory complications?

Correct answer: A

Rationale: Splinting the chest with a pillow helps manage pain during deep breathing and coughing, which is essential to prevent respiratory complications such as atelectasis or pneumonia after thoracic surgery. Holding a pillow against the chest while coughing (splinting) supports the incision site and reduces the pain associated with deep breathing and coughing. Encouraging shallow breaths (Choice B) can lead to respiratory complications due to inadequate lung expansion. Increasing pain medication (Choice C) should be done based on healthcare provider orders and not solely for this situation. Avoiding deep breathing exercises (Choice D) can worsen respiratory function and increase the risk of complications.

3. When caring for a patient with a fresh tracheostomy, what is the nurse’s first priority?

Correct answer: B

Rationale: The correct answer is B: Ensuring the tracheostomy ties are secure. This is the nurse's first priority because it is critical to prevent accidental decannulation, which could compromise the patient’s airway. Providing humidified oxygen, suctioning the tracheostomy tube, and monitoring for signs of infection are important aspects of care but ensuring the tracheostomy ties' security takes precedence to maintain the patient's airway.

4. Which condition is most commonly associated with a "bull's eye" rash?

Correct answer: A

Rationale: The correct answer is A: Lyme disease. The "bull's eye" rash, or erythema migrans, is a hallmark of early Lyme disease, caused by the bacterium Borrelia burgdorferi. Choice B, Rocky Mountain spotted fever, presents with a different type of rash. Choice C, Syphilis, typically presents with a painless ulcer and rash but not a "bull's eye" rash. Choice D, Toxoplasmosis, does not typically present with a "bull's eye" rash.

5. Which type of isolation precaution is required for a patient with tuberculosis (TB)?

Correct answer: C

Rationale: The correct answer is C: Airborne precautions. Tuberculosis (TB) is transmitted via airborne particles, thus requiring airborne precautions to prevent the spread of infection. This includes using an N95 respirator to filter out small infectious particles. Droplet precautions (Choice A) are used for diseases that spread through large respiratory droplets. Contact precautions (Choice B) are for direct or indirect contact with the patient or their environment. Standard precautions (Choice D) are used for all patients to prevent the spread of infection through blood, bodily fluids, non-intact skin, and mucous membranes.

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