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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.
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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.
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 hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the diagnosis. What action by the nurse is best?
- A. Assess the client's support system
- B. Assist in finding one change the client can control
- C. Determine what stressors the client faces in daily life
- D. Inquire about delegating some of the client's obligations
Correct Answer: B
Rationale: All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Assisting the client in choosing one change they feel optimistic about controlling is the most effective approach to build confidence and promote adherence.
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.
A nurse is working with a client who takes atorvastatin (Lipitor). The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.3 mg/dL. What action by the nurse is best?
- A. Ask if the client eats grapefruit
- B. Assess the client for dehydration
- C. Facilitate admission to the hospital
- D. Obtain a random urinalysis
Correct Answer: A
Rationale: There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.