Nokea
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.
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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.
The client is prescribed nitroglycerin for angina. Which instruction should the nurse include?
- A. Take it every day even if you feel well.
- B. Place the tablet under your tongue.
- C. Swallow the tablet with water.
- D. Apply it as a patch on your chest.
Correct Answer: B
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption to relieve angina.
The nurse is teaching a class on atherosclerosis. Which statement describes the scientific rationale as to why diabetes is a risk factor for developing atherosclerosis?
- A. Glucose combines with carbon monoxide, instead of with oxygen, and this leads to oxygen deprivation of tissues.
- B. Diabetes stimulates the sympathetic nervous system, resulting in peripheral constriction that increases the development of atherosclerosis.
- C. Diabetes speeds the atherosclerotic process by thickening the basement membrane of both large and small vessels.
- D. The increased glucose combines with the hemoglobin, which causes deposits of plaque in the lining of the vessels.
Correct Answer: C
Rationale: Diabetes accelerates atherosclerosis by thickening vascular basement membranes (C), promoting plaque. Carbon monoxide (A), sympathetic stimulation (B), and glucose-hemoglobin (D) are incorrect mechanisms.
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 teaching the client diagnosed with deep vein thrombosis and prescribed warfarin. Which should the nurse teach the client? Select all that apply.
- A. Keep a constant amount of green, leafy vegetables in the diet.
- B. Instruct the client to have regular INR laboratory work done.
- C. Tell the client to go to the hospital immediately for any bleeding.
- D. Inform the client to notify the HCP if having dark, tarry stools.
- E. Encourage the client to avoid all green vegetables.
- F. Have the client take iron orally to prevent bleeding.
Correct Answer: A,B,D
Rationale: Constant green vegetable intake (A), regular INR (B), and reporting tarry stools (D) ensure safe warfarin use. Avoiding all greens (E) is unnecessary, and iron (C) doesn’t prevent bleeding. Immediate hospital for any bleeding (C) is excessive; minor bleeding requires HCP contact.