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A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
- A. I will wait 15 minutes after drinking coffee to measure my blood pressure.
- B. I will measure my blood pressure while my arm is elevated above my heart.
- C. I should remove constrictive clothing prior to measuring my blood pressure.
- D. I should measure my blood pressure immediately after eating breakfast.
Correct Answer: C
Rationale: The correct answer is C: "I should remove constrictive clothing prior to measuring my blood pressure." Removing constrictive clothing ensures accurate blood pressure measurement by allowing the cuff to fit properly on the arm without any restrictions, leading to a more reliable reading. Choice A is incorrect as coffee can temporarily increase blood pressure. Choice B is incorrect because the arm should be at heart level, not elevated. Choice D is incorrect as blood pressure should be measured on an empty stomach for accuracy.
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A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?
- A. How to operate the portable suction machine
- B. How to secure the tracheostomy tube with ties at the back of the neck
- C. How to change the nondisposable tracheostomy tube daily
- D. How to change the tracheostomy dressing using clean technique
Correct Answer: A
Rationale: The correct answer is A: How to operate the portable suction machine. This information is crucial in maintaining a patent airway for the client with a tracheostomy. Suctioning helps to remove secretions and prevent blockages, ensuring proper oxygenation. It is essential for the partner to know how to operate the suction machine safely and effectively.
Choice B is incorrect as securing the tracheostomy tube with ties is important, but it is not the priority in this scenario. Choice C is incorrect as changing the nondisposable tracheostomy tube daily is not a standard practice and can introduce infection risk. Choice D is incorrect as changing the tracheostomy dressing should be done using sterile technique, not clean technique, to prevent infection.
A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?
- A. First-degree atrioventricular block
- B. Complete heart block
- C. Premature atrial complexes
- D. Atrial fibrillation
Correct Answer: A
Rationale: The correct answer is A: First-degree atrioventricular block. A constant P-R interval of 0.35 seconds indicates a delay in the conduction of electrical impulses from the atria to the ventricles. In first-degree AV block, the delay causes a prolonged P-R interval, which is consistent with the 0.35 seconds observed. This dysrhythmia is characterized by a consistent delay but all atrial impulses are conducted to the ventricles.
B: Complete heart block would show a lack of association between P waves and QRS complexes, with no relationship between atrial and ventricular activity.
C: Premature atrial complexes are early electrical impulses originating in the atria, resulting in abnormal P waves and irregular rhythm, not a constant P-R interval.
D: Atrial fibrillation is characterized by chaotic electrical activity in the atria, leading to an irregularly irregular ventricular response, not a constant P-R interval.
The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe? Select all that apply.
- A. Limit alcohol intake to 0 oz per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an anti-obesity medication.
- D. Administer an antihypertensive medication.
- E. Limit foods high in potassium.
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A: Limiting alcohol intake helps manage conditions like hypertension. B: Keeping fat intake below 35% helps prevent heart disease. D: Administering antihypertensive medication is essential for managing high blood pressure. C: Administering anti-obesity medication may not be necessary if the client's weight is not the primary concern. E: Limiting foods high in potassium is not necessary unless the client has specific medical conditions requiring it. Therefore, choices C and E are incorrect as they are not the priorities for the client's care in this scenario.
A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?
- A. Report of discomfort at the insertion site
- B. Heart rate 90/min
- C. Bounding pulses in the affected extremity
- D. Hematoma over the insertion site
Correct Answer: C
Rationale: The correct answer is C: Bounding pulses in the affected extremity. Bounding pulses can indicate arterial occlusion or other circulatory complications post-cardiac catheterization, requiring immediate intervention. A: Discomfort at the insertion site is expected and can be managed with pain medication. B: Heart rate of 90/min is within normal range. D: Hematoma over the insertion site is common after the procedure and may resolve on its own.
A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make?
- A. We can review some information to help you select a safe alternative practitioner.
- B. If there are therapies available to you, your provider will tell you about them.
- C. Feel free to try whatever therapies that fit within your personal belief system.
- D. I'm sure you can find alternative remedies through an online support group.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Option A is the correct choice because it acknowledges the client's interest in alternative therapies and offers to review information to help select a safe practitioner. This response shows support for the client's autonomy and involves them in the decision-making process. It also ensures the client's safety by emphasizing the importance of selecting a reputable practitioner.
Incorrect Choices:
B: This choice assumes the provider will automatically inform the client about therapies, which may not always be the case. It does not actively involve the client in their care.
C: While it supports the client's autonomy, it lacks guidance on selecting a safe practitioner and may not prioritize the client's safety.
D: Suggesting online support groups for remedies may not ensure the safety or efficacy of the therapies, and it does not involve professional guidance.