Nokea
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.
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A student nurse asks what essential hypertension is. What response by the registered nurse is best?
- A. It is caused by another disease
- B. It means it must be treated immediately
- C. It has no specific cause
- D. It refers to severe and life-threatening hypertension
Correct Answer: C
Rationale: Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension caused by another disease is secondary hypertension. Severe, life-threatening hypertension is malignant hypertension.
A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Administering preoperative medication
- B. Ensuring the consent is signed
- C. Marking pulses with a pen
- D. Raising the side rails of the bed
- E. Recording the client's vital signs
Correct Answer: D,E
Rationale: The UAP can raise the side rails for safety and record vital signs. Administering medications, ensuring consent, and marking pulses should be done by the registered nurse.
A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client's weight has decreased significantly since the last visit. What action by the nurse is best?
- A. Ask if the weight loss was intentional
- B. Encourage a high-protein, high-fiber diet
- C. Measure for new compression stockings
- D. Review a 3-day food recall diary
Correct Answer: C
Rationale: Compression stockings must fit correctly to be effective. After significant weight loss, the client should be re-measured for new stockings. The other options are appropriate but less critical.
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding indicates a priority outcome for this client has been met?
- A. Pain rated as 2/10 after medication
- B. Distal pulse on affected extremity 2+/4
- C. Client remains on bedrest as directed
- D. Verifies understanding of procedure
Correct Answer: B
Rationale: Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4 indicates good perfusion, meeting a priority outcome. The other options are important but secondary to circulation.
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.