Nokea
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.
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The nurse is planning care for a client diagnosed with arterial occlusive disease. Which exercise instructions would the nurse teach the client?
- A. Have the client perform isometric exercises 30 minutes each day.
- B. Tell the client to start exercising on a stair stepper for 15 minutes.
- C. Inform the client that warm-up exercises are not necessary.
- D. Teach the client to walk in well-fitting shoes on level ground.
Correct Answer: D
Rationale: Walking on level ground in well-fitting shoes (D) promotes circulation in PAD. Isometric exercises (A) increase BP, stair steppers (B) are too strenuous, and warm-ups (C) are necessary.
The nurse just received the a.m. shift report. Which client should the nurse assess first?
- A. The client diagnosed with coronary artery disease who has a BP of 170/100.
- B. The client diagnosed with DVT who is complaining of chest pain.
- C. The client diagnosed with pneumonia who has a pulse oximeter reading of 98%.
- D. The client diagnosed with ulcerative colitis who has non-bloody diarrhea.
Correct Answer: B
Rationale: Chest pain in DVT (B) suggests pulmonary embolism, a life-threatening emergency. Hypertension (A) is urgent but less immediate, SpO2 98% (C) is normal, and diarrhea (D) is non-emergent.
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.
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 and an unlicensed assistive personnel (UAP) are caring for a 64-year-old client who is four (4) hours postoperative bilateral femoral-popliteal bypass surgery. Which nursing task should be delegated to the UAP?
- A. Monitor the continuous passive motion machine.
- B. Assist the client to the bedside commode.
- C. Feed the client the evening meal.
- D. Elevate the foot of the client's bed.
Correct Answer: C
Rationale: Feeding the client (C) is within the UAP’s scope and safe post-bypass. Monitoring CPM (A), assisting to commode (B), and elevating bed (D) require nursing judgment due to circulation concerns.