Nokea
The nurse is assessing a client with hypertension. Which finding requires immediate action?
- A. Blood pressure of 160/100 mmHg
- B. Headache rated 4/10
- C. Blurred vision and confusion
- D. Pulse rate of 88 beats per minute
Correct Answer: C
Rationale: Blurred vision and confusion indicate a hypertensive crisis, which can lead to organ damage and requires immediate intervention.
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Which instruction should the nurse include for a client with heart failure to monitor fluid status?
- A. Check blood pressure twice daily.
- B. Weigh yourself every morning.
- C. Record urine color daily.
- D. Measure abdominal girth weekly.
Correct Answer: B
Rationale: Daily weight monitoring detects fluid retention early, as 1 liter of fluid equals approximately 2.2 pounds.
Which intervention should the nurse prioritize for a client with heart failure experiencing shortness of breath?
- A. Administer oxygen as prescribed.
- B. Place the client in a supine position.
- C. Encourage deep breathing exercises.
- D. Restrict all fluid intake.
Correct Answer: A
Rationale: Administering oxygen improves oxygenation in clients with shortness of breath due to heart failure.
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 diagnosed with essential hypertension asks the nurse, 'I don’t know why the doctor is worried about my blood pressure. I feel just great.' Which statement by the nurse would be the most appropriate response?
- A. Damage can be occurring to your heart and kidneys even if you feel great.'
- B. Unless you have a headache, your blood pressure is probably within normal limits.'
- C. When is the last time you saw your doctor? Does he know you are feeling great?'
- D. Your blood pressure reflects how well your heart is working.'
Correct Answer: A
Rationale: Hypertension causes silent organ damage (heart, kidneys) (A), even without symptoms. Headaches (B) aren’t reliable, doctor visits (C) are irrelevant, and heart function (D) is vague.
The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply.
- A. Place sequential compression devices on both legs.
- B. Instruct the client to stay in bed and not ambulate.
- C. Encourage fluids and a diet high in roughage.
- D. Monitor IV site every four (4) hours and prn.
- E. Assess Homans’ sign every 24 hours.
Correct Answer: A,C,D
Rationale: Compression devices (A), fluids/fiber (C), and IV monitoring (D) prevent DVT progression and complications. Bedrest (B) is not absolute (early ambulation is encouraged), and Homans’ sign (E) is unreliable.