Nokea
The client with hypertension reports dizziness when standing. What should the nurse assess first?
- A. Blood glucose level
- B. Orthostatic blood pressure
- C. Urine output
- D. Respiratory rate
Correct Answer: B
Rationale: Dizziness when standing suggests orthostatic hypotension, which should be confirmed by measuring blood pressure in lying, sitting, and standing positions.
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Which finding in a client taking a thiazide diuretic for hypertension requires immediate action?
- A. Potassium level of 2.8 mEq/L
- B. Blood pressure of 140/90 mmHg
- C. Mild fatigue
- D. Weight loss of 1 pound
Correct Answer: A
Rationale: Hypokalemia from thiazide diuretics can cause arrhythmias, requiring immediate intervention.
Which instruction should the nurse provide to a client with a new implantable cardioverter-defibrillator (ICD)?
- A. Avoid strong magnetic fields.
- B. Carry heavy bags on the affected side.
- C. Resume contact sports in 2 weeks.
- D. Ignore any shocks you feel.
Correct Answer: A
Rationale: Strong magnetic fields can interfere with ICD function, so clients should avoid them.
The 66-year-old male client has his blood pressure (BP) checked at a health fair. The BP is 168/98. Which action should the nurse implement first?
- A. Recommend that the client have his blood pressure checked in one (1) month.
- B. Instruct the client to see his health-care provider as soon as possible.
- C. Discuss the importance of eating a low-salt, low-fat, low-cholesterol diet.
- D. Explain that this BP is within the normal range for an elderly person.
Correct Answer: B
Rationale: BP 168/98 indicates stage 2 hypertension, requiring prompt HCP evaluation (B). Waiting a month (A) delays care, diet discussion (C) is secondary, and normal range (D) is incorrect (normal is <120/80).
The nurse is caring for the client on strict bedrest. Which intervention is priority when caring for this client?
- A. Encourage the client to drink liquids.
- B. Perform active range-of-motion exercises.
- C. Elevate the head of the bed to 45 degrees.
- D. Provide a high-fiber diet to the client.
Correct Answer: D
Rationale: High-fiber diet (D) prevents constipation, a priority in bedrest to avoid straining and DVT risk. Fluids (A) are important, active ROM (B) is incorrect (passive needed), and HOB elevation (C) is not primary.
The client with varicose veins asks why they need to wear compression stockings. What is the best response by the nurse?
- A. They prevent blood clots from forming.
- B. They help push blood back to the heart.
- C. They reduce pain in the legs.
- D. They keep your legs warm.
Correct Answer: B
Rationale: Compression stockings apply pressure to promote venous return, helping blood flow back to the heart.