Nokea
A client is receiving treatment for hypertension. Which of these findings would be most concerning to the nurse?
- A. A heart rate of 90 beats per minute
- B. A blood pressure of 120/80 mm Hg
- C. A respiratory rate of 16 breaths per minute
- D. A temperature of 98.6 degrees Fahrenheit
Correct Answer: C
Rationale: The correct answer is C. A respiratory rate of 16 breaths per minute is within normal limits; however, changes in breathing patterns can indicate respiratory distress, which is concerning, especially in a client receiving treatment for hypertension. A heart rate of 90 beats per minute may not be alarming if the client is at rest. A blood pressure of 120/80 mm Hg is within the normal range for a healthy adult. A temperature of 98.6 degrees Fahrenheit is also considered normal, showing no immediate cause for concern in this scenario.
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The client is receiving discharge teaching for heart failure. Which statement made by the client indicates a need for further teaching?
- A. I will weigh myself daily and report any significant weight gain to my healthcare provider.
- B. I will limit my sodium intake to help manage my heart failure.
- C. I will take my medications as prescribed by my healthcare provider.
- D. I will stop taking my medications if I feel better.
Correct Answer: D
Rationale: Choice D is the correct answer because stopping medications when feeling better can be harmful in heart failure. It is essential to complete the full course of medication as prescribed by the healthcare provider to effectively manage heart failure. Choices A, B, and C demonstrate good understanding and compliance with heart failure management strategies, such as monitoring weight, restricting sodium intake, and adhering to prescribed medications, respectively.
Which bed position is preferred for use with a client in an extended care facility on a falls risk prevention protocol?
- A. All 4 side rails up, wheels locked, bed closest to door
- B. Lower side rails up, bed facing the doorway
- C. Knees bent, head slightly elevated, bed in the lowest position
- D. Bed in the lowest position, wheels locked, place bed against the wall
Correct Answer: D
Rationale: The correct answer is D. Placing the bed in the lowest position, ensuring wheels are locked, and positioning it against the wall is the preferred bed position for a client in an extended care facility on a falls risk prevention protocol. This setup helps minimize the risk of falls by providing a stable and secure environment. Choices A, B, and C do not address key factors such as having the bed in the lowest position and placing it against the wall, which are crucial in preventing falls in such a setting.
A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?
- A. Protamine
- B. Amicar
- C. Imferon
- D. Diltiazem
Correct Answer: A
Rationale: Protamine is the antidote for heparin overdose. It works by neutralizing the anticoagulant effects of heparin. Amicar (Choice B) is used to treat excessive bleeding due to elevated fibrinolytic activity and is not the antidote for heparin overdose. Imferon (Choice C) is an iron supplement and is not indicated for heparin overdose. Diltiazem (Choice D) is a calcium channel blocker used to treat hypertension and angina, not for heparin overdose. Therefore, the correct choice is Protamine (Choice A).
A client underwent coronary artery bypass grafting and is learning about following a low-cholesterol diet. Which of the following food choices indicates the client's understanding of these dietary instructions?
- A. Liver
- B. Milk
- C. Beans
- D. Eggs
Correct Answer: C
Rationale: The correct answer is C: Beans. Beans are an excellent choice for individuals following a low-cholesterol diet post-coronary artery bypass grafting due to their low cholesterol content. Beans are high in fiber and protein, making them a heart-healthy option. Choice A, Liver, is high in cholesterol and should be avoided in a low-cholesterol diet. Choice B, Milk, contains cholesterol and saturated fats, which are not ideal for this diet. Choice D, Eggs, are also high in cholesterol and should be limited in a low-cholesterol diet.
A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, the oxygen is running at 6 liters per minute, the client's color is flushed, and his respirations are 8 per minute. What should the nurse do first?
- A. Obtain a 12-lead EKG
- B. Place the client in high Fowler's position
- C. Lower the oxygen rate
- D. Take baseline vital signs
Correct Answer: C
Rationale: In a client with COPD, it is crucial to prevent carbon dioxide retention by avoiding high oxygen levels. As the client's oxygen is running at 6 liters per minute and he is showing signs of oxygen toxicity, such as flushed color and low respirations, the nurse's priority should be to lower the oxygen rate. This action helps prevent worsening the client's condition. Obtaining an EKG, placing the client in high Fowler's position, or taking baseline vital signs are important assessments but addressing the potential oxygen toxicity takes precedence in this scenario.