Nokea
The nurse is developing an education plan for clients with hypertension. Which of the following long-term goals is most appropriate for the nurse to emphasize?
- A. Develop a plan to limit stress.
- B. Participate in a weight reduction program.
- C. Commit to regular exercise.
- D. Monitor blood pressure regularly.
Correct Answer: D
Rationale: Regular blood pressure monitoring empowers clients to track their hypertension and adjust lifestyle or medication as needed.
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The nurse is caring for a preterm neonate in the NICU. Which intervention is essential to prevent retinopathy of prematurity?
- A. Monitor oxygen saturation
- B. Administer vitamin D
- C. Provide high-calorie formula
- D. Keep the incubator at 37°C
Correct Answer: A
Rationale: Excessive oxygen can contribute to retinopathy of prematurity in preterm neonates. Monitoring oxygen saturation ensures levels remain within a safe range.
A young adult has been bitten by a human and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client to receive:
- A. An injection of tetanus toxoid.
- B. An application of a corticosteroid cream.
- C. Closure of the wound with sutures.
- D. Testing for tuberculosis.
Correct Answer: A
Rationale: A human bite with broken skin and a tetanus shot over 5 years ago warrants tetanus toxoid to prevent tetanus infection. The other options are not indicated for this scenario.
A client has a viral (coxsackie B) or trypanosomal (parasite) infection. The nurse should further assess the client for:
- A. Myocarditis.
- B. Myocardial infarction.
- C. Renal failure.
- D. Liver failure.
Correct Answer: A
Rationale: Coxsackie B and trypanosomal infections are associated with myocarditis, an inflammation of the heart muscle, which requires further assessment.
The nurse is caring for a client with a history of burns. Which of the following laboratory findings indicates a need for intervention?
- A. Serum potassium of 5.5 mEq/L.
- B. Serum sodium of 135 mEq/L.
- C. Hemoglobin of 12 g/dL.
- D. White blood cell count of 8,000/mm³.
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a complication of burns due to tissue damage, requiring intervention.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed sotalol (Betapace). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Hyperglycemia.
- D. Weight gain.
Correct Answer: B
Rationale: Sotalol, a beta-blocker, can cause bradycardia, requiring close monitoring of heart rate.