Nokea
The nurse is caring for a male client diagnosed with essential hypertension. Which information regarding antihypertensive medication should the nurse teach?
- A. Teach the client to take his blood pressure four (4) times each day.
- B. Instruct the client to have regular blood levels of the medication checked.
- C. Explain the need to rise slowly from a lying or sitting position.
- D. Demonstrate how to use a blood glucose meter daily.
Correct Answer: C
Rationale: Antihypertensives cause orthostatic hypotension; rising slowly (C) prevents falls. Frequent BP checks (A) are excessive, drug levels (B) are rarely monitored, and glucose meters (D) are irrelevant.
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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.
The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse?
- A. The client takes a stool softener every day at dinnertime.
- B. The client is wearing a Medic Alert bracelet.
- C. The client takes vitamin E over-the-counter medication.
- D. The client has purchased a new recliner that will elevate the legs.
Correct Answer: C
Rationale: Vitamin E (C) increases bleeding risk with DVT anticoagulation, requiring intervention. Stool softeners (A), Medic Alert (B), and leg elevation (D) are appropriate.
The nurse identifies the concept of clotting for a client diagnosed with a deep vein thrombosis. Which clinical manifestations support the diagnosis?
- A. Brown-purple discoloration on the calf.
- B. Bright red skin on the lower legs.
- C. Swelling in the calf, warmth, and tenderness.
- D. Pain after walking for short distances that resolve with rest.
Correct Answer: C
Rationale: Swelling, warmth, and tenderness (C) are classic DVT signs. Brown-purple (A) is venous insufficiency, red skin (B) is nonspecific, and pain with walking (D) is arterial.
Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours postoperative abdominal aortic aneurysm repair?
- A. Absent bilateral pedal pulses.
- B. Complaints of pain at the site of the incision.
- C. Distended, tender abdomen.
- D. An elevated temperature of 100°F.
Correct Answer: A
Rationale: Absent pedal pulses (A) suggest graft occlusion, a surgical emergency. Incisional pain (B), distension (C), and low-grade fever (D) are expected or less urgent.
The nurse is preparing to administer 7.5 mg of an oral anticoagulant. The medication available is 5 mg per tablet. How many tablets should the nurse administer?
Correct Answer: 1.5
Rationale: Dose required: 7.5 mg. Available: 5 mg/tablet. 7.5 ÷ 5 = 1.5 tablets. Administer 1.5 tablets (e.g., one whole and one half, if scored).