Nokea
The nurse collects the following assessment data on the client who has no known health problems: BP 135/89 mm Hg; BMI 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum potassium 4.0 mEq/L; LDL cholesterol 200 mg/dL; HDL cholesterol 25 mg/dL; and triglycerides 180 mg/dL. Which intervention should the nurse anticipate?
- A. A low-calorie regular diet
- B. A statin antilipidemic medication
- C. A thiazide diuretic medication
- D. Low-salt, low-saturated-fat, low-potassium diet
Correct Answer: B
Rationale: A statin antilipidemic should be prescribed to manage the client’s hypercholesterolemia. It will lower the LDL cholesterol and triglycerides and increase the HDL cholesterol. A low-calorie diet is unnecessary with a normal BMI, a diuretic is not indicated for slightly elevated BP, and a low-potassium diet is not needed with normal potassium levels.
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The nurse is assessing the client. At which area should the nurse place the stethoscope to best auscultate the client’s murmur associated with mitral regurgitation?
- A. Line A
- B. Line B
- C. Line C
- D. Line D
Correct Answer: D
Rationale: Mitral regurgitation is heard at the location of the mitral valve (line D) and should be auscultated with the bell of the stethoscope at the fifth intercostal space, left midclavicular line. The bell is used to auscultate low-pitched sounds. Lines A, B, and C correspond to aortic, pulmonic, and tricuspid valves, respectively.
The nurse is assessing the client who underwent repair of an aortic aneurysm with graft placement 30 minutes ago. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. What should be the nurse’s priority?
- A. Recheck the pulse in 5 minutes.
- B. Reposition the affected leg.
- C. Notify the surgeon of the finding.
- D. Document that the pulse is absent.
Correct Answer: C
Rationale: The nurse should notify the surgeon immediately to reassess the client. The loss of the pulse could signify graft occlusion or embolization. Rechecking, repositioning, or documenting delays critical intervention.
The nurse, assessing the client hospitalized following an MI, obtains these VS: BP 78/38 mm Hg, HR 128, RR 32. The nurse notifies the HCP concerned that the client may be experiencing which most life-threatening complication?
- A. Pulmonary embolism
- B. Cardiac tamponade
- C. Cardiomyopathy
- D. Cardiogenic shock
Correct Answer: D
Rationale: The symptoms are indicative of cardiogenic shock (decreased cardiac output leading to inadequate tissue perfusion and initiation of the shock syndrome). Pulmonary embolism and tamponade could cause shock but are less likely post-MI, and cardiomyopathy is not an acute complication.
While preparing the client for a computed tomography angiography (CTA), the client asks the nurse what the test Will entail. Which should be the nurse’s correct response?
- A. “A CTA uses magnetic fields to visualize the major vessels Within your body.”
- B. “A CTA is an invasive procedure that requires a small incision into an artery.”
- C. “A CTA is a quick procedure that requires anesthesia for about 20 minutes.”
- D. “A CTA is a scan that includes a contrast dye injection to visualize your arteries.”
Correct Answer: D
Rationale: The correct response should explain CTA. CTA is a noninvasive spiral CT scan using contrast dye to yield a 3-dimensional image of the arteries. It does not use magnetic fields (A), require incisions (B), or anesthesia (C).
The nurse is to administer 40 mg of furosemide to the client in HF. The prefilled syringe reads 100 mg/mL. In order to give the correct dose, how many milliliters should the nurse administer to the client?
Correct Answer: 0.4
Rationale: Use a proportion formula: 100 mg: 1 mL :: 40 mg: X mL; 100X = 40; X = 0.4. The nurse should administer 0.4 mL of furosemide.