Nokea
The 45-year-old male client diagnosed with essential hypertension has decided not to take his medications. The client's BP is 178/94, indicating a perfusion issue. Which question should the nurse ask the client first?
- A. Do you have the money to buy your medication?'
- B. Does the medication give unwanted side effects?'
- C. Did you quit taking the medications because you don’t feel bad?'
- D. Can you tell me why you stopped taking the medication?'
Correct Answer: D
Rationale: Asking why the client stopped (D) is open-ended, identifying barriers like side effects (B) or asymptomatic disease (C). Financial issues (A) are secondary.
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Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease?
- A. Assess the client's radial pulse.
- B. Assess the client's serum potassium level.
- C. Assess the client's glucometer reading.
- D. Assess the client's pulse oximeter reading.
Correct Answer: B
Rationale: Loop diuretics cause hypokalemia, which can precipitate dysrhythmias in CAD. Assessing potassium (B) is critical. Pulse (A), glucose (C), and SpO2 (D) are less directly related.
Which laboratory data confirm the diagnosis of congestive heart failure?
- A. Chest x-ray (CXR).
- B. Liver function tests.
- C. Blood urea nitrogen (BUN).
- D. Beta-type natriuretic peptide (BNP).
Correct Answer: D
Rationale: Elevated BNP (D) is specific for CHF, reflecting ventricular stress. CXR (A) shows fluid but is not diagnostic, liver tests (B) and BUN (C) are nonspecific.
The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first?
- A. Administer oxygen via nasal cannula.
- B. Evaluate the client's urinary output.
- C. Assess the client for cardiac complications.
- D. Encourage the client to use the incentive spirometer.
Correct Answer: C
Rationale: Increased pain in pericarditis may indicate complications like tamponade. Assessing for cardiac complications (C) is the priority. Oxygen (A), urinary output (B), and spirometry (D) are secondary.
The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse?
- A. Muffled heart sounds.
- B. Nondistended jugular veins.
- C. Bounding peripheral pulses.
- D. Pericardial friction rub.
Correct Answer: A
Rationale: Muffled heart sounds (A) suggest cardiac tamponade, a life-threatening complication requiring immediate attention. Non-distended JVD (B) is normal, bounding pulses (C) are unrelated, and friction rub (D) is expected.
The nurse is assisting with a synchronized cardioversion on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take?
- A. Wait until the machine discharges.
- B. Shout 'all clear' and don’t touch the bed.
- C. Make sure the client is all right.
- D. Increase the joules and redischarge.
Correct Answer: A
Rationale: A pause in synchronized cardioversion is normal as the machine syncs with the QRS complex; wait for discharge (A). 'All clear' (B) is for defibrillation, checking client (C) is premature, and increasing joules (D) is incorrect.