Nokea
The nurse is assessing a client with mitral regurgitation. Which finding is expected?
- A. High-pitched holosystolic murmur
- B. Bradycardia
- C. Clear lung sounds
- D. Hypotension
Correct Answer: A
Rationale: Mitral regurgitation causes a high-pitched holosystolic murmur due to blood flowing back into the left atrium.
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Which teaching point should the nurse include for a client with cardiomyopathy? Select all that apply.
- A. Monitor for signs of heart failure.
- B. Avoid alcohol consumption.
- C. Take medications as prescribed.
- D. Engage in high-intensity exercise.
- E. Report sudden weight gain.
- F. Limit fluid intake as advised.
Correct Answer: A,B,C,E,F
Rationale: Monitoring heart failure signs, avoiding alcohol, adhering to medications, reporting weight gain, and limiting fluids prevent complications.
As the nurse provides discharge instructions to the client with varicose veins, which activity should the nurse suggest the client avoid?
- A. Walking in athletic shoes.
- B. Jogging a mile a day.
- C. Sitting with crossed knees.
- D. Wearing wool socks.
Correct Answer: C
Rationale: Sitting with crossed knees can compress veins, worsening venous stasis in clients with varicose veins.
The client with coronary artery disease reports chest pain. What should the nurse do first?
- A. Administer oxygen.
- B. Check vital signs.
- C. Give nitroglycerin as prescribed.
- D. Place the client in a supine position.
Correct Answer: C
Rationale: Nitroglycerin is the first-line treatment for angina to relieve chest pain by dilating coronary arteries.
The nurse is preparing a client for valve replacement surgery. Which preoperative teaching is most important?
- A. You will need lifelong anticoagulant therapy.
- B. You can resume heavy lifting in 2 weeks.
- C. You will not need antibiotics before dental procedures.
- D. You should avoid all physical activity post-surgery.
Correct Answer: A
Rationale: Lifelong anticoagulation is often required post-valve replacement to prevent clot formation.
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).