Free NCLEX-RN Exam Braindumps (page: 194)

Page 194 of 431

A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:

  1. Continue to monitor the foot
  2. Notify the physician immediately
  3. Reposition and reassess the foot
  4. Assure the client that his foot is fine

Answer(s): B

Explanation:

(A) The client is losing blood supply to his left foot. Continuing to monitor the foot will not help restore the blood supply to the foot. (B) The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the foot and/or leg. (C) The presenting symptoms are of an emergency nature and require immediate intervention. (D) This action would be giving the client false assurance.



A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:

  1. Continue to monitor the foot
  2. Notify the physician immediately
  3. Reposition and reassess the foot
  4. Assure the client that his foot is fine

Answer(s): B

Explanation:

(A) The client is losing blood supply to his left foot. Continuing to monitor the foot will not help restore the blood supply to the foot. (B) The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the foot and/or leg. (C) The presenting symptoms are of an emergency nature and require immediate intervention. (D) This action would be giving the client false assurance.



A client who has gout is most likely to form which type of renal calculi?

  1. Struvite stones
  2. Staghorn calculi
  3. Uric acid stones
  4. Calcium stones

Answer(s): C

Explanation:

(A) The presence of urinary tract infection is a factor in the formation of struvite stones. (B) Staghorn calculi is the other name for struvite stones associated with urinary tract infection. (C) Clients who have gout form uric acid stones. (D) Clients who have increased urinary excretion of calcium form calcium stones.



A client who has gout is most likely to form which type of renal calculi?

  1. Struvite stones
  2. Staghorn calculi
  3. Uric acid stones
  4. Calcium stones

Answer(s): C

Explanation:

(A) The presence of urinary tract infection is a factor in the formation of struvite stones. (B) Staghorn calculi is the other name for struvite stones associated with urinary tract infection. (C) Clients who have gout form uric acid stones. (D) Clients who have increased urinary excretion of calcium form calcium stones.



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