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A nurse is prioritizing care for four clients. Which client should the nurse see first?
- A. A client who needs assistance to ambulate
- B. A client with a new prescription for captopril (Capoten)
- C. A hypertensive client with a blood pressure of 182/92 mm Hg
- D. A client who needs pain medication prior to a dressing change
Correct Answer: B
Rationale: Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falls if the client attempts to get up without assistance. The other clients' conditions are less urgent.
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An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice nurse. What statement by the client may indicate a barrier to proper foot care?
- A. I nearly always wear comfy sweatpants and house shoes
- B. I'm glad I get energy assistance so my house isn't so cold
- C. I check my feet every day for cuts or sores
- D. My hands shake when I try to do things requiring coordination
Correct Answer: D
Rationale: Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails, indicating a barrier to proper foot care. The nurse should refer this client to a podiatrist.
A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)
- A. Apply compression stockings
- B. Assist with ambulation
- C. Assist with deep breathing
- D. Offer fluids frequently
- E. Teach leg exercises
Correct Answer: A,B,D
Rationale: The UAP can apply compression stockings, assist with ambulation, and offer fluids to prevent DVT. Deep breathing does not reduce DVT risk, and teaching is a nursing function.
Which factors does the nurse teach as contributing to aneurysm formation? (Select all that apply.)
- A. Atherosclerosis
- B. Down syndrome
- C. Frequent heartburn
- D. History of hypertension
- E. History of smoking
Correct Answer: A,D,E
Rationale: Atherosclerosis, hypertension, and smoking are major risk factors for aneurysm formation. Down syndrome and heartburn are not related.
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 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.