Nokea
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.
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The nurse is assessing a client on admission to the hospital. The client's leg appears with dependent rubor. What action by the nurse is best?
- A. Assess the client's ankle-brachial index
- B. Elevate the leg above the heart
- C. Obtain an ice pack to provide comfort
- D. Administer heparin sodium
Correct Answer: A
Rationale: Dependent rubor is a classic finding in peripheral arterial disease. The nurse should measure the ankle-brachial index to assess the severity. Elevating the leg or using ice could worsen circulation, and heparin is not indicated for this condition.
A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse?
- A. Administer oxygen via non-rebreather mask
- B. Ensure the client has a patent airway
- C. Prepare to assist with suturing the artery
- D. Start two large-bore IVs with normal saline
Correct Answer: B
Rationale: Airway always takes priority, followed by breathing and circulation. Ensuring a patent airway is the first step before other interventions.
A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?
- A. Administer prescribed pain medication
- B. Assess distal pulses and skin color
- C. Document the findings in the client's chart
- D. Notify the surgeon immediately
Correct Answer: B
Rationale: Assessing distal pulses and skin color is the priority to ensure adequate circulation post-surgery. Severe pain could indicate complications like graft occlusion. Administering pain medication, documenting, or notifying the surgeon are secondary until circulation is confirmed.
A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.)
- A. Dietary restrictions
- B. Driving restrictions
- C. Follow-up laboratory monitoring
- D. Drug-drug interactions
- E. Reason to take medication
Correct Answer: A,C,D,E
Rationale: Clients on warfarin need instructions on dietary restrictions, follow-up monitoring, drug interactions, and the reason for the medication, per The Joint Commission's Core Measures. Driving restrictions are not typically required.
A nurse is caring for a client who weighs 207 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your answer using a whole number.) __ mg
- A. 90
- B. 80
- C. 100
- D. 70
Correct Answer: A
Rationale: The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 207 pounds (94 kg), so the nurse anticipates administering the maximum dose of 90 mg.