Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The client’s chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?
A. Complaints of muscle cramps with exercise
Complaints of muscle cramps with exercise. While muscle cramps with exercise can be a symptom of peripheral arterial disease (PAD), they are more commonly associated with the earlier stages of the disease, known as intermittent claudication.
B. Pedal pulses are +1 bilaterally
Pedal pulses are +1 bilaterally. Reduced or absent pedal pulses can be a sign of PAD, but a finding of +1 pedal pulses does not necessarily correlate with stage III of the disease.
C. Complaints of burning pain during the night
Complaints of burning pain during the night. Stage III PAD, also known as critical limb ischemia, is characterized by more severe symptoms, including discomfort or pain in the feet or toes, even while at rest. Symptoms tend to worsen at night.
D. Tissue that is blackened on the great toe
Tissue that is blackened on the great toe. This is a sign of gangrene, which is a severe and potentially life-threatening complication of PAD2. However, it is not a typical finding in stage III PAD, and would more likely be seen in the most advanced stage of the disease.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Nurs 200 Proctored Exam Roxoborouh Memorial College. Take the full exam now
Full Explanation
Choice A rationale
Complaints of muscle cramps with exercise. While muscle cramps with exercise can be a symptom of peripheral arterial disease (PAD), they are more commonly associated with the earlier stages of the disease, known as intermittent claudication.
Choice B rationale
Pedal pulses are +1 bilaterally. Reduced or absent pedal pulses can be a sign of PAD, but a finding of +1 pedal pulses does not necessarily correlate with stage III of the disease.
Choice C rationale
Complaints of burning pain during the night. Stage III PAD, also known as critical limb ischemia, is characterized by more severe symptoms, including discomfort or pain in the feet or toes, even while at rest. Symptoms tend to worsen at night.
Choice D rationale
Tissue that is blackened on the great toe. This is a sign of gangrene, which is a severe and potentially life-threatening complication of PAD2. However, it is not a typical finding in stage III PAD, and would more likely be seen in the most advanced stage of the disease.
Similar Questions
Which client does the nurse recognize to have the greatest risk of an adverse reaction if prescribed potassium Penicillin G?
A. 55-year-old woman with coronary artery disease
55-year-old woman with coronary artery disease. While patients with coronary artery disease often have multiple comorbidities and may be on medications that could interact with Penicillin G, there is no specific increased risk of adverse reactions to Penicillin G in this population.
B. 21-year-old college senior who is being treated for Streptococcus
21-year-old college senior who is being treated for Streptococcus. Penicillin G is often used to treat Streptococcus infections. There is no specific increased risk of adverse reactions in this population unless the patient has a known allergy to penicillins.
C. 23-year-old woman who recently delivered and has mastitis
23-year-old woman who recently delivered and has mastitis. Penicillin G can be used to treat mastitis, an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. There is no specific increased risk of adverse reactions in this population unless the patient has a known allergy to penicillins.
D. 65-year-old man with dehydration .
65-year-old man with dehydration. Dehydration can affect kidney function, and Penicillin G is excreted by the kidneys. Therefore, patients with dehydration or any other condition that reduces kidney function are at a higher risk of adverse reactions to Penicillin G3.
Full Explanation
Choice A rationale
55-year-old woman with coronary artery disease. While patients with coronary artery disease often have multiple comorbidities and may be on medications that could interact with Penicillin G, there is no specific increased risk of adverse reactions to Penicillin G in this population.
Choice B rationale
21-year-old college senior who is being treated for Streptococcus. Penicillin G is often used to treat Streptococcus infections. There is no specific increased risk of adverse reactions in this population unless the patient has a known allergy to penicillins.
Choice C rationale
23-year-old woman who recently delivered and has mastitis. Penicillin G can be used to treat mastitis, an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. There is no specific increased risk of adverse reactions in this population unless the patient has a known allergy to penicillins.
Choice D rationale
65-year-old man with dehydration. Dehydration can affect kidney function, and Penicillin G is excreted by the kidneys. Therefore, patients with dehydration or any other condition that reduces kidney function are at a higher risk of adverse reactions to Penicillin G3.
A nurse gives a client 10 units of insulin lispro at 0630. When should the client have breakfast?
A. 0640
The correct answer is Choice A. Insulin lispro is a fast-acting insulin that starts to work about 15 minutes after injection. Therefore, the client should eat within 15 minutes of taking the insulin to prevent hypoglycemia. So, if the client takes the insulin at 0630, they should start eating at 06404
B. 0650
C. 0700
D. 0710
Full Explanation
The correct answer is Choice A. Insulin lispro is a fast-acting insulin that starts to work about 15 minutes after injection. Therefore, the client should eat within 15 minutes of taking the insulin to prevent hypoglycemia. So, if the client takes the insulin at 0630, they should start eating at 06404
A nurse is caring for a client with a heart murmur due to mitral valve disease. Where would the nurse hear the murmur the loudest?
A. Fourth intercostal space, right sternal border
B. Second intercostal space, right sternal border
C. Fifth intercostal space, left midclavicular line
A heart murmur due to mitral valve disease is typically heard loudest over the mitral area, which is located at the fifth intercostal space in the left midclavicular line.
D. Third intercostal space, left midclavicular line .
Full Explanation
A heart murmur due to mitral valve disease is typically heard loudest over the mitral area, which is located at the fifth intercostal space in the left midclavicular line.