The client tells the nurse that his cholesterol level is 240 mg/dL. Which action should the nurse implement?
- A. Praise the client for having a normal cholesterol level.
- B. Explain that the client needs to lower the cholesterol level.
- C. Discuss dietary changes that could help increase the level.
- D. Allow the client to ventilate feelings about the blood test result.
Correct Answer: B
Rationale: Cholesterol 240 mg/dL (B) is high (>200 is abnormal), requiring education to lower it. Praising (A) is incorrect, increasing (C) is harmful, and venting (D) is secondary.
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The health-care provider ordered a femoral angiogram for the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement?
- A. Explain that this procedure will be done at the bedside.
- B. Discuss with the client that he or she will be on bedrest with bathroom privileges.
- C. Inform the client that no intravenous access will be needed.
- D. Inform the client that fluids will be increased after the procedure.
Correct Answer: D
Rationale: Femoral angiograms require increased fluids post-procedure (D) to flush contrast dye. Bedside (A) is incorrect (done in cath lab), bedrest is strict (B), and IV access (C) is needed.
The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first?
- A. Complete a neurovascular assessment.
- B. Use the Doppler device.
- C. Instruct the client to hang the feet off the side of the bed.
- D. Wrap the legs in a blanket.
Correct Answer: B
Rationale: Absent pedal pulse in PAD requires Doppler use (B) to confirm blood flow. Neurovascular assessment (A) follows, dependent position (C) worsens ischemia, and blankets (D) are irrelevant.
The nurse is preparing a client for valve replacement surgery. Which preoperative teaching is most important?
- A. You will need lifelong anticoagulant therapy.
- B. You can resume heavy lifting in 2 weeks.
- C. You will not need antibiotics before dental procedures.
- D. You should avoid all physical activity post-surgery.
Correct Answer: A
Rationale: Lifelong anticoagulation is often required post-valve replacement to prevent clot formation.
The nurse is assessing a client with endocarditis. Which finding is most concerning?
- A. Fever of 102°F
- B. Mild fatigue
- C. Heart rate of 90 beats per minute
- D. Blood pressure of 130/85 mmHg
Correct Answer: A
Rationale: Fever is a hallmark of endocarditis and may indicate ongoing infection, requiring prompt attention.
Which intervention should the nurse prioritize for a client with heart failure experiencing shortness of breath?
- A. Administer oxygen as prescribed.
- B. Place the client in a supine position.
- C. Encourage deep breathing exercises.
- D. Restrict all fluid intake.
Correct Answer: A
Rationale: Administering oxygen improves oxygenation in clients with shortness of breath due to heart failure.
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