Nokea
The client with heart failure asks why they need to limit sodium intake. What is the best response?
- A. Sodium causes your heart to beat faster.
- B. Sodium makes your body retain fluid.
- C. Sodium increases your blood sugar.
- D. Sodium weakens your heart muscle.
Correct Answer: B
Rationale: Sodium promotes fluid retention, which increases cardiac workload in heart failure.
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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 client is one (1) day postoperative abdominal aortic aneurysm repair. Which information from the unlicensed assistive personnel (UAP) would require immediate intervention from the nurse?
- A. The client refuses to turn from the back to the side.
- B. The client’s urinary output is 90 mL in six (6) hours.
- C. The client wants to sit on the side of the bed.
- D. The client’s vital signs are T 98, P 90, R 18, and BP 130/70.
Correct Answer: B
Rationale: Urine output of 90 mL in 6 hours (B) (<30 mL/hr) suggests renal compromise, requiring immediate intervention. Refusing to turn (A), sitting (C), and normal vitals (D) are less urgent.
Which assessment finding in a client with endocarditis requires immediate action?
- A. Splinter hemorrhages under nails
- B. Mild joint pain
- C. New heart murmur
- D. Fatigue after activity
Correct Answer: C
Rationale: A new heart murmur may indicate valve damage or worsening infection, requiring urgent evaluation.
The client with hypertension asks why they need to limit stress. What is the best response?
- A. Stress causes fluid retention.
- B. Stress increases your heart rate and blood pressure.
- C. Stress reduces oxygen to your heart.
- D. Stress weakens your immune system.
Correct Answer: B
Rationale: Stress activates the sympathetic nervous system, increasing heart rate and blood pressure.
Which arterial anticoagulant medication would the nurse anticipate being prescribed for a client diagnosed with arterial occlusive disease?
- A. Clopidogrel.
- B. Streptokinase.
- C. Protamine sulfate.
- D. Enoxaparin.
Correct Answer: A
Rationale: Clopidogrel (A), an antiplatelet, is used in arterial occlusive disease to prevent thrombosis. Streptokinase (B) is a thrombolytic, protamine (C) reverses heparin, and enoxaparin (D) is for DVT.