Nokea
The client diagnosed with essential hypertension asks the nurse, 'I don’t know why the doctor is worried about my blood pressure. I feel just great.' Which statement by the nurse would be the most appropriate response?
- A. Damage can be occurring to your heart and kidneys even if you feel great.'
- B. Unless you have a headache, your blood pressure is probably within normal limits.'
- C. When is the last time you saw your doctor? Does he know you are feeling great?'
- D. Your blood pressure reflects how well your heart is working.'
Correct Answer: A
Rationale: Hypertension causes silent organ damage (heart, kidneys) (A), even without symptoms. Headaches (B) aren’t reliable, doctor visits (C) are irrelevant, and heart function (D) is vague.
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The client is prescribed nitroglycerin for angina. Which instruction should the nurse include?
- A. Take it every day even if you feel well.
- B. Place the tablet under your tongue.
- C. Swallow the tablet with water.
- D. Apply it as a patch on your chest.
Correct Answer: B
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption to relieve angina.
The client is receiving prophylactic low molecular weight heparin. There are no PT/PTT or INR results on the client's chart since admission three (3) days ago. Which action should the nurse implement?
- A. Administer the medication as ordered.
- B. Notify the health-care provider immediately.
- C. Obtain the PT/PTT and INR prior to administering the medication.
- D. Hold the medication until the HCP makes rounds.
Correct Answer: A
Rationale: LMWH (e.g., enoxaparin) does not require PT/PTT/INR monitoring (A); it’s administered as ordered. Notifying HCP (B), obtaining labs (C), or holding (D) are unnecessary.
The client had an abdominal aortic aneurysm repair two (2) days ago. Which intervention should the nurse implement first?
- A. Assess the client’s bowel sounds.
- B. Administer an IV prophylactic antibiotic.
- C. Encourage the client to splint the incision.
- D. Ambulate the client in the room with assistance.
Correct Answer: A
Rationale: Assessing bowel sounds (A) is first to detect ileus, common post-AAA repair. Antibiotics (B), splinting (C), and ambulation (D) follow based on assessment.
The client with coronary artery disease reports chest pain. What should the nurse do first?
- A. Administer oxygen.
- B. Check vital signs.
- C. Give nitroglycerin as prescribed.
- D. Place the client in a supine position.
Correct Answer: C
Rationale: Nitroglycerin is the first-line treatment for angina to relieve chest pain by dilating coronary arteries.
Which risk factor revealed in the client's health history is most closely related to the development of varicose veins?
- A. The client's mother also has varicose veins.
- B. The client was a track athlete in high school.
- C. The client is a 50-year-old corporate executive.
- D. The client smokes one pack of cigarettes daily.
Correct Answer: A
Rationale: Varicose veins have a strong genetic component, so a family history, such as the client's mother having varicose veins, is a significant risk factor.