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The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which intervention should the nurse implement?
- A. Notify the health-care provider if the potassium level is 3.8 mEq.
- B. Question administering the medication if the BP is less than 90/60 mm Hg.
- C. Do not administer the medication if the client's radial pulse is greater than 100.
- D. Monitor the client's BP while he or she is lying, standing, and sitting.
Correct Answer: B
Rationale: Beta blockers lower BP; BP <90/60 (B) indicates hypotension, warranting withholding the dose. Potassium 3.8 (A) is normal, pulse >100 (C) is not a contraindication, and orthostatic checks (D) are routine but not primary.
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The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first?
- A. Check the PTT and PT/INR.
- B. Check with the HCP to see which drug should be discontinued.
- C. Administer both medications.
- D. Discontinue the heparin because the client is receiving Coumadin.
Correct Answer: A
Rationale: Check PTT (heparin) and PT/INR (warfarin) (A) to assess therapeutic levels before action. HCP check (B), administering (C), or discontinuing (D) depend on lab results (heparin often continues briefly with warfarin).
The client diagnosed with subclavian steal syndrome has undergone surgery. Which assessment data would warrant immediate intervention by the nurse?
- A. The client’s pedal pulse on the left leg is absent.
- B. The client complains of numbness in the right hand.
- C. The client’s brachial pulse is strong and bounding.
- D. The client’s capillary refill time (CRT) is less than three (3) seconds.
Correct Answer: B
Rationale: Numbness in the right hand (B) post-subclavian surgery suggests nerve or vascular compromise, requiring immediate action. Absent pedal pulse (A) is unrelated, strong brachial pulse (C) is normal, and CRT <3 sec (D) is normal.
The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client's record?
- A. Peripheral vascular disease.
- B. Intermittent claudication.
- C. Deep vein thrombosis.
- D. Dependent rubor.
Correct Answer: B
Rationale: Muscle cramping/pain with walking (B) is intermittent claudication, a hallmark of arterial occlusive disease. PVD (A) is broader, DVT (C) causes swelling/pain at rest, and dependent rubor (D) is a skin color change.
When offered the pain medication, the client says to the nurse, 'If that's Motrin, I don't want it. It makes me sick to my stomach.' What is the most appropriate nursing action at this time?
- A. Tell the client that the drug is ibuprofen.
- B. Explain that the prescribed medication must be taken.
- C. Advise the client to take the drug with plenty of water.
- D. Report the information to the charge nurse.
Correct Answer: D
Rationale: Reporting the client's adverse reaction to the charge nurse ensures proper communication and potential adjustment of the medication plan.
Which instruction should the nurse include for a client with valvular heart disease?
- A. Avoid high-sodium foods.
- B. Increase caffeine intake.
- C. Limit fluid intake.
- D. Avoid regular exercise.
Correct Answer: A
Rationale: Avoiding high-sodium foods prevents fluid retention, reducing strain on the heart.