Nokea
The nurse is discussing discharge teaching with the client who is three (3) days postoperative abdominal aortic aneurysm repair. Which discharge instructions should the nurse include when teaching the client?
- A. Notify the HCP of any redness or irritation of the incision.
- B. Do not lift anything that weighs more than 20 pounds.
- C. Inform the client there may be pain not relieved with pain medication.
- D. Stress the importance of having daily bowel movements.
Correct Answer: A,B
Rationale: Notifying HCP of redness (A) and limiting lifting to <20 lbs (B) prevent infection and graft stress. Unrelieved pain (C) requires evaluation, and daily BMs (D) are not critical.
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Which interventions should the nurse discuss with the client diagnosed with atherosclerosis? Select all that apply.
- A. Include the significant other in the discussion.
- B. Stop smoking or using any type of tobacco products.
- C. Maintain a sedentary lifestyle as much as possible.
- D. Avoid stressful situations.
- E. Daily isometric exercises are important.
Correct Answer: A,B,D
Rationale: Including significant other (A), stopping smoking (B), and avoiding stress (D) reduce atherosclerosis risk. Sedentary lifestyle (C) worsens it, and isometric exercises (E) increase BP.
The client with pericarditis asks why they hear a rubbing sound. What is the best response?
- A. It's caused by fluid in your lungs.
- B. It's due to inflammation of the heart's lining.
- C. It's a normal heart sound.
- D. It's from high blood pressure.
Correct Answer: B
Rationale: A pericardial friction rub is caused by inflamed pericardial layers rubbing together.
Which laboratory value should the nurse monitor closely in a client with heart failure? Select all that apply.
- A. B-type natriuretic peptide (BNP)
- B. Serum potassium
- C. Blood urea nitrogen (BUN)
- D. Hemoglobin A1c
- E. Serum sodium
- F. Platelet count
Correct Answer: A,B,C,E
Rationale: BNP indicates heart failure severity, potassium and sodium affect fluid balance and medication safety, and BUN reflects renal perfusion.
The client on the telemetry unit diagnosed with a thromboembolism is complaining of chest pain and anxiety. Which action should the nurse implement first?
- A. Stay with the client and call the Rapid Response Team (RRT).
- B. Assess the client’s vital signs.
- C. Have the unlicensed assistive personnel (UAP) stay with the client.
- D. Check the client’s telemetry reading.
Correct Answer: A
Rationale: Chest pain/anxiety in thromboembolism suggests pulmonary embolism; calling RRT (A) ensures rapid intervention. Vitals (B), UAP (C), and telemetry (D) follow.
Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease?
- A. An anticoagulant medication.
- B. An antihypertensive medication.
- C. An antiplatelet medication.
- D. A muscle relaxant.
Correct Answer: C
Rationale: Antiplatelet medications (e.g., aspirin, clopidogrel) (C) prevent clot formation in PAD. Anticoagulants (A) are for DVT, antihypertensives (B) for BP, and muscle relaxants (D) are irrelevant.