Nokea
The nurse is caring for a client with congestive heart failure (CHF). The nurse should anticipate a prescription for which medication?
- A. Enalapril
- B. Verapamil
- C. Lovastatin
- D. Gemfibrozil
Correct Answer: A
Rationale: Enalapril, an ACE inhibitor, reduces afterload and preload in CHF, improving cardiac function.
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While auscultating a client's bowel sounds, the nurse notes a swooshing sound to the left of the umbilical area. What would be the nurse's priority action?
- A. Percuss over the area to assess for dullness
- B. Notify the primary healthcare provider (PHCP)
- C. Gently palpate the abdomen to assess for tenderness
- D. Ask the client about recent bowel movements
Correct Answer: B
Rationale: A swooshing sound may indicate an abdominal aortic aneurysm, a life-threatening condition requiring immediate PHCP notification.
The nurse is caring for a client who appears to be developing heart failure (HF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis?
- A. Basic metabolic panel (BMP)
- B. B-type natriuretic peptide (BNP)
- C. Lipid profile
- D. Troponin
Correct Answer: B
Rationale: BNP is a specific biomarker elevated in heart failure, reflecting ventricular stress and fluid overload.
The nurse is caring for a client and upon initial evaluation the nurse suspects femoral artery occlusion. The nurse should take which action?
- A. Elevate the affected leg
- B. Apply a cold compress
- C. Notify the primary healthcare provider (PHCP)
- D. Perform passive range of motion to the affected leg
Correct Answer: C
Rationale: Femoral artery occlusion is a medical emergency requiring immediate notification of the PHCP for vascular intervention.
A client is being discharged following the insertion of a permanent pacemaker. Which of the following should be included in the client's discharge instructions?
- A. Air travel will not be possible due to airport screening equipment.
- B. You will need to discard any radios at home that have antennas.
- C. Computed tomography (CT) scans are not permitted with this device.
- D. You should use your cellular phone on the opposite side of the generator.
Correct Answer: D
Rationale: Using a cell phone on the opposite side of the pacemaker reduces electromagnetic interference.
What is the correct documentation of the patient's peripheral pulse when the finding is that the posterior tibial pulse is weak and thready?
- A. Grade C posterior tibial pulse
- B. Posterior tibial pulse is Grade B
- C. The client's posterior tibial is 2
- D. Posterior tibial pulse is 1
Correct Answer: D
Rationale: A weak and thready pulse is documented as a 1+ on a 0-4 scale, where 1 indicates a barely palpable pulse.