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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.
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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 home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse?
- A. The client takes a stool softener every day at dinnertime.
- B. The client is wearing a Medic Alert bracelet.
- C. The client takes vitamin E over-the-counter medication.
- D. The client has purchased a new recliner that will elevate the legs.
Correct Answer: C
Rationale: Vitamin E (C) increases bleeding risk with DVT anticoagulation, requiring intervention. Stool softeners (A), Medic Alert (B), and leg elevation (D) are appropriate.
The client diagnosed with essential hypertension asks the nurse, 'Why do I have high blood pressure?' Which response by the nurse would be most appropriate?
- A. You probably have some type of kidney disease that causes the high BP.'
- B. More than likely you have had a diet high in salt, fat, and cholesterol.'
- C. There is no specific cause for hypertension, but there are many known risk factors.'
- D. You are concerned that you have high blood pressure. Let's sit down and talk.'
Correct Answer: C
Rationale: Essential hypertension has no single cause but multiple risk factors (e.g., genetics, lifestyle) (C). Kidney disease (A) or diet (B) may contribute but aren’t definitive, and concern (D) avoids the question.
Which should the nurse include in the plan of care for a client diagnosed with venous stasis ulcers? Select all that apply.
- A. Elevate the legs while sitting.
- B. Wear antiembolism compression stockings.
- C. Avoid injury to the lower limbs.
- D. Trim the toenails straight across.
- E. Do not apply moisturizer to the lower legs.
- F. Allow the legs to hang over the bed in a dependent position.
Correct Answer: A,B,C,D
Rationale: Leg elevation (A), compression stockings (B), injury avoidance (C), and straight toenail trimming (D) manage venous ulcers. Moisturizer (E) is beneficial, and dependent position (F) worsens edema.
Which instruction should the nurse include for a client with valvular heart disease?
- A. Avoid high-sodium foods.
- B. Increase caffeine intake.
- C. Limit fluid intake.
- D. Avoid regular exercise.
Correct Answer: A
Rationale: Avoiding high-sodium foods prevents fluid retention, reducing strain on the heart.