Nokea
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
- A. Do you have trouble affording your medications?
- B. Most people with hypertension do not have symptoms
- C. Most people get severe morning headaches
- D. You need to take your medicine or you will get kidney failure
Correct Answer: A
Rationale: Most people with hypertension are asymptomatic, although a small percentage do have symptoms. Since the client has already admitted nonadherence, assessing barriers such as affordability is the most effective response to improve compliance.
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A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)
- A. Administer pain medication
- B. Assess distal pulses every 10 minutes
- C. Have the client sign a surgical consent
- D. Notify the Rapid Response Team
- E. Take vital signs every 10 minutes
Correct Answer: B,D,E
Rationale: This client may have a rupturing aneurysm. The nurse should notify the Rapid Response Team and perform frequent assessments of pulses and vital signs. Pain medication could lower blood pressure further, and consent should be handled after the physician explains the procedure.
The nurse is caring for four hypertensive clients. Which drug/laboratory value combination should the nurse report immediately to the health care provider?
- A. Furosemide (Lasix)/potassium 2.1 mEq/L
- B. Hydrochlorothiazide/potassium 3.5 mEq/L
- C. Spironolactone (Aldactone)/potassium 5.1 mEq/L
- D. Losartan/sodium 135 mEq/L
Correct Answer: A
Rationale: Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is critically low and should be reported immediately. A potassium level of 5.1 mEq/L is on the high side but not as critical. The other laboratory values are within normal ranges.
The nurse is assessing a client on admission to the hospital. The client's leg appears with dependent rubor. What action by the nurse is best?
- A. Assess the client's ankle-brachial index
- B. Elevate the leg above the heart
- C. Obtain an ice pack to provide comfort
- D. Administer heparin sodium
Correct Answer: A
Rationale: Dependent rubor is a classic finding in peripheral arterial disease. The nurse should measure the ankle-brachial index to assess the severity. Elevating the leg or using ice could worsen circulation, and heparin is not indicated for this condition.
A nurse is caring for a client who weighs 207 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your answer using a whole number.) __ mg
- A. 90
- B. 80
- C. 100
- D. 70
Correct Answer: A
Rationale: The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 207 pounds (94 kg), so the nurse anticipates administering the maximum dose of 90 mg.
What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)
- A. Administering mild analgesics for pain
- B. Applying elastic compression stockings
- C. Elevating the legs when sitting or lying
- D. Reminding the client to do leg exercises
- E. Teaching the client about surgical options
Correct Answer: B,C,D
Rationale: The plan of care for varicose veins includes elastic compression stockings, exercise, and elevation. Administering analgesics is pharmacologic, and teaching about surgical options is not a comfort measure.