Nokea
The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse?
- A. The telemetry reads normal sinus rhythm.
- B. The client has a weight gain of 2 kg within 1 to 2 days.
- C. The client's blood pressure is 148/92.
- D. The client's serum potassium level is 4.5 mEq.
Correct Answer: B
Rationale: Weight gain of 2 kg in 1–2 days (B) indicates fluid retention, a serious issue in hypertension requiring intervention. Normal sinus rhythm (A), BP 148/92 (C), and K+ 4.5 (D) are not urgent.
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The nurse is administering heparin to a client with a DVT. Which laboratory value should the nurse monitor closely?
- A. International normalized ratio (INR)
- B. Activated partial thromboplastin time (aPTT)
- C. Platelet count
- D. Red blood cell count
Correct Answer: B
Rationale: Heparin's anticoagulant effect is monitored using aPTT to ensure therapeutic dosing and prevent bleeding.
The nurse is teaching a class on arterial essential hypertension. Which modifiable risk factors would the nurse include when preparing this presentation?
- A. Include information on retinopathy and nephropathy.
- B. Discuss sedentary lifestyle and smoking cessation.
- C. Include discussions on family history and gender.
- D. Provide information on a low-fiber and high-salt diet.
Correct Answer: B
Rationale: Modifiable risk factors for hypertension include sedentary lifestyle and smoking (B), which can be changed. Retinopathy/nephropathy (A) are complications, family history/gender (C) are non-modifiable, and low-fiber/high-salt (D) promotes hypertension.
The nurse is teaching a client with pericarditis about activity restrictions. Which instruction is most appropriate?
- A. Resume normal activity immediately.
- B. Rest and avoid strenuous activity.
- C. Engage in high-intensity exercise.
- D. Lift heavy objects to build strength.
Correct Answer: B
Rationale: Rest prevents exacerbation of pericardial inflammation and promotes healing.
The nurse is admitting a client diagnosed with peripheral vascular disease. Which data support a diagnosis of venous insufficiency?
- A. The client has bright red skin on the lower extremities.
- B. The client has a brownish purple area on the lower legs.
- C. The client complains of pain after ambulating for short distances.
- D. The client has nonhealing wounds on the toes and ankles.
Correct Answer: B
Rationale: Brownish purple skin (B) indicates hemosiderin from venous stasis. Red skin (A) is nonspecific, pain with walking (C) is arterial, and toe/ankle wounds (D) are arterial.
The nurse is caring for clients on a telemetry floor. Which nursing task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)?
- A. Teach the client how to perform a glucometer check.
- B. Assist feeding the client diagnosed with congestive heart failure.
- C. Check the cholesterol level for the client diagnosed with atherosclerosis.
- D. Assist the nurse to check the unit of blood at the client's bedside.
Correct Answer: B
Rationale: Feeding a CHF client (B) is within UAP scope and safe. Teaching glucometer (A), checking cholesterol (C), and blood verification (D) require nursing judgment.