Nokea
The nurse is assessing a client with dilated cardiomyopathy. Which finding is expected?
- A. Jugular vein distension
- B. Hypertension
- C. Dry skin
- D. Tachypnea
Correct Answer: A
Rationale: Dilated cardiomyopathy causes reduced cardiac output, leading to jugular vein distension from fluid backup.
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The client is four (4) hours postoperative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?
- A. Assist the client to ambulate.
- B. Assess the client's bilateral pedal pulses.
- C. Maintain a continuous IV heparin drip.
- D. Provide a clear liquid diet to the client.
Correct Answer: B
Rationale: Assessing pedal pulses (B) monitors graft patency post-AAA repair, critical at 4 hours. Ambulation (A) is premature, heparin (C) is not routine, and diet (D) awaits bowel function.
The client diagnosed with Buerger’s disease (thromboangiitis obliterans) asks the nurse, 'What is the worst thing that could happen if I don’t quit smoking? I love my cigarettes.' Which statement is the nurse’s best response?
- A. You are concerned about quitting smoking. Let’s sit down and talk about it.'
- B. Many clients end up having to have an amputation, especially a leg.'
- C. You should consider attending a smoking cessation program.'
- D. Your coronary arteries could block and cause a heart attack.'
Correct Answer: B
Rationale: Smoking worsens Buerger’s, risking severe ischemia and amputation (B). Concern (A) avoids the question, cessation programs (C) are secondary, and heart attack (D) is less specific.
Which finding in a client with mitral stenosis requires immediate action?
- A. Heart rate of 100 beats per minute
- B. New onset of atrial fibrillation
- C. Blood pressure of 140/90 mmHg
- D. Mild fatigue
Correct Answer: B
Rationale: New-onset atrial fibrillation increases the risk of thromboembolism in mitral stenosis, requiring immediate intervention.
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 and an unlicensed assistive personnel (UAP) are bathing a bedfast client. Which action by the UAP warrants immediate intervention?
- A. The UAP closes the door and cubicle curtain before undressing the client.
- B. The UAP begins to massage and rub lotion into the client’s calf.
- C. The UAP tests the temperature of the water with the wrist before starting.
- D. The UAP collects all the linens and supplies and brings them to the room.
Correct Answer: B
Rationale: Massaging calves (B) risks dislodging a clot in a bedfast client (high DVT risk). Privacy (A), water testing (C), and supplies (D) are appropriate.