Nokea
The nurse is demonstrating the use of a blood pressure sphygmomanometer to a client newly diagnosed with hypertension. Which should the nurse teach the client? Select all that apply.
- A. Tell the client to make sure the cuff is placed over an artery.
- B. Teach the client to notify the health-care provider if the BP is >160/100.
- C. Instruct the client about orthostatic hypotension.
- D. Encourage the client to keep a record of the blood pressure readings.
- E. Explain that even when the blood pressure is within normal limits the medication should still be taken.
Correct Answer: A,B,C,D,E
Rationale: Cuff over artery (A), notifying HCP for BP >160/100 (B), orthostatic precautions (C), BP log (D), and continuing meds (E) ensure proper BP management. All apply.
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Which instruction should the nurse include when providing discharge instructions to a client diagnosed with peripheral arterial disease?
- A. Encourage the client to use a heating pad on the lower extremities.
- B. Demonstrate to the client the correct way to apply elastic support hose.
- C. Instruct the client to walk daily for at least 30 minutes.
- D. Tell the client to check both feet for red areas at least once a week.
Correct Answer: C
Rationale: Daily walking for 30 minutes (C) promotes collateral circulation in PAD. Heating pads (A) risk burns, elastic hose (B) are for venous disease, and weekly checks (D) are insufficient (daily needed).
Which question should the nurse ask the male client diagnosed with aortoiliac disease during the admission interview?
- A. Do you have trouble sitting for long periods of time?'
- B. How often do you have a bowel movement and urinate?'
- C. When you lie down, do you feel throbbing in your abdomen?'
- D. Have you experienced any problems having sexual intercourse?'
Correct Answer: D
Rationale: Aortoiliac disease can cause erectile dysfunction due to reduced pelvic blood flow, making sexual intercourse issues (D) relevant. Sitting (A), bowel/urination (B), and throbbing (C) are less specific.
Which activity should the nurse advise a client with a new pacemaker to avoid?
- A. Swimming in a chlorinated pool
- B. Using a microwave oven
- C. Lifting heavy objects for 6 weeks
- D. Walking for exercise
Correct Answer: C
Rationale: Avoiding heavy lifting for 6 weeks prevents dislodgement of pacemaker leads.
Which teaching point should the nurse include for a client with endocarditis? Select all that apply.
- A. Report fever or chills immediately.
- B. Brush teeth gently to avoid gum bleeding.
- C. Avoid sharing toothbrushes.
- D. Take antibiotics for the full course.
- E. Monitor for signs of heart failure.
- F. Limit physical activity during treatment.
Correct Answer: A,B,C,D,E,F
Rationale: Reporting symptoms, gentle oral hygiene, avoiding shared items, completing antibiotics, monitoring heart failure, and limiting activity prevent complications.
Which actions should the surgical scrub nurse take to prevent personally developing a DVT?
- A. Keep the legs in a dependent position and stand as still as possible.
- B. Flex the leg muscles and change the leg positions frequently.
- C. Wear white socks and shoes that have an elevated heel.
- D. Ask the surgeon to allow the nurse to take a break midway through each surgery.
Correct Answer: B
Rationale: Flexing muscles and changing positions (B) promote venous return, preventing DVT. Dependent position (A) increases risk, socks/heels (C) are irrelevant, and breaks (D) are impractical.