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The client with a pacemaker asks how to check if it is working. What is the best response?
- A. Check your pulse regularly.
- B. Monitor your blood pressure daily.
- C. Weigh yourself every morning.
- D. Measure your temperature daily.
Correct Answer: A
Rationale: Checking the pulse ensures the pacemaker is maintaining an appropriate heart rate.
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The client with peripheral artery disease asks why they need to walk daily. What is the best response?
- A. It strengthens your leg muscles.
- B. It promotes collateral circulation.
- C. It reduces swelling in your legs.
- D. It prevents venous ulcers.
Correct Answer: B
Rationale: Walking stimulates the development of collateral vessels, improving blood flow in peripheral artery disease.
Which intervention should the nurse prioritize for a client with ventricular tachycardia?
- A. Administer lidocaine as prescribed.
- B. Check blood pressure.
- C. Encourage deep breathing.
- D. Apply oxygen at 2 L/min.
Correct Answer: A
Rationale: Lidocaine is used to suppress ventricular tachycardia, a life-threatening arrhythmia.
The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first?
- A. Check the PTT and PT/INR.
- B. Check with the HCP to see which drug should be discontinued.
- C. Administer both medications.
- D. Discontinue the heparin because the client is receiving Coumadin.
Correct Answer: A
Rationale: Check PTT (heparin) and PT/INR (warfarin) (A) to assess therapeutic levels before action. HCP check (B), administering (C), or discontinuing (D) depend on lab results (heparin often continues briefly with warfarin).
The nurse is assessing a client with mitral regurgitation. Which finding is expected?
- A. High-pitched holosystolic murmur
- B. Bradycardia
- C. Clear lung sounds
- D. Hypotension
Correct Answer: A
Rationale: Mitral regurgitation causes a high-pitched holosystolic murmur due to blood flowing back into the left atrium.
The nurse is caring for a male client diagnosed with essential hypertension. Which information regarding antihypertensive medication should the nurse teach?
- A. Teach the client to take his blood pressure four (4) times each day.
- B. Instruct the client to have regular blood levels of the medication checked.
- C. Explain the need to rise slowly from a lying or sitting position.
- D. Demonstrate how to use a blood glucose meter daily.
Correct Answer: C
Rationale: Antihypertensives cause orthostatic hypotension; rising slowly (C) prevents falls. Frequent BP checks (A) are excessive, drug levels (B) are rarely monitored, and glucose meters (D) are irrelevant.