Nokea
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.
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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 nurse is caring for a client on IV infusion of heparin. What actions does the nurse include in the client's plan? (Select all that apply.)
- A. Assess the client for bleeding
- B. Monitor the daily activated partial thromboplastin time (aPTT) results
- C. Stop the IV if aPTT shows baseline
- D. Use an IV pump for the infusion
- E. Weigh the client daily on the same scale
Correct Answer: A,B,D
Rationale: Assessing for bleeding, monitoring aPTT, and using an IV pump are critical for heparin safety. Stopping the IV at baseline aPTT is incorrect, as therapeutic levels are 1.5-2 times baseline. Weighing is not directly related.
A nurse wants to provide community service that helps meet the goals of Healthy People 2020 related to cardiovascular disease and stroke. What activity would best meet this goal?
- A. Teach a class on heart-healthy diets
- B. Participate in blood pressure screenings at the mall
- C. Provide pamphlets on heart disease at the grocery store
- D. Set up an information booth at the pet store
Correct Answer: B
Rationale: An important goal of Healthy People 2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether it was normal or high. Blood pressure screenings in a public place best meet this goal.
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 client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client states the drug is dangerous. What action by the nurse is best?
- A. Assess the reason behind the client's fear
- B. Remind the client about laboratory monitoring
- C. Tell the client drugs are safer today than before
- D. Warn the client about consequences of noncompliance
Correct Answer: A
Rationale: The first step is to assess the reason behind the client's fear, which may be related to a past experience. Addressing the specific concern is critical for effective teaching and compliance. The other options do not address the client's fear directly.