The nurse is giving discharge teaching to the client followi...

The nurse is giving discharge teaching to the client following aortic valve replacement surgery with a synthetic valve. The nurse evaluates that the client understands the teaching when the client states plans to take which action? Select all that apply.

A. Use a soft toothbrush for dental hygiene.
B. Floss teeth daily to prevent plaque.
C. Wear loose-fitting T-shirts or tops.
D. Use an electric razor for shaving.
E. Consume foods high in vitamin K.

Correct Answer: A;C;D

Rationale: The client understands when stating: A) Using a soft toothbrush to reduce bleeding risk on anticoagulants; C) Wearing loose-fitting clothing to avoid incision friction; D) Using an electric razor to prevent cuts. Flossing (B) increases bleeding and endocarditis risk, and high vitamin K (E) antagonizes anticoagulants.

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The nurse is assessing the client who underwent repair of an aortic aneurysm with graft placement 30 minutes ago. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. What should be the nurse’s priority?

A. Recheck the pulse in 5 minutes.
B. Reposition the affected leg.
C. Notify the surgeon of the finding.
D. Document that the pulse is absent.

Correct Answer: C

Rationale: The nurse should notify the surgeon immediately to reassess the client. The loss of the pulse could signify graft occlusion or embolization. Rechecking, repositioning, or documenting delays critical intervention.

The nurse observes sinus tachycardia with new-onset ST segment elevation on the ECG monitor of the client reporting chest pain. Which should be the nurse’s priority intervention?

A. Draw blood for cardiac enzymes STAT
B. Call the cardiac catheterization laboratory
C. Apply 1 inch of nitroglycerin paste topically
D. Apply 4 liters of oxygen via nasal cannula

Correct Answer: D

Rationale: The nurse’s priority intervention should be to increase oxygen to the heart muscle. Applying 4 liters of oxygen via nasal cannula addresses the immediate need to improve myocardial oxygenation in an evolving MI indicated by ST elevation. Cardiac enzymes, catheterization, and nitroglycerin are secondary actions.

The nurse is admitting the client experiencing dyspnea from HF and COPD with high CO2 levels. Which interventions should the nurse plan? Select all that apply.

A. Apply oxygen 6 liters per nasal cannula.
B. Elevate the head of the bed 30 to 40 degrees.
C. Weigh daily in the am. after the client voids.
D. Teach client pursed-lip breathing techniques.
E. Turn and reposition the client every 1 to 2 hours.

Correct Answer: B;C;D

Rationale: The nurse should plan: B) Elevating the head of the bed to promote lung expansion; C) Daily weights to assess fluid retention; D) Pursed-lip breathing to conserve energy and slow breathing. High oxygen flow (A) may depress hypoxic drive in COPD, and repositioning (E) is less specific to dyspnea management.

The nurse collects the following assessment data on the client who has no known health problems: BP 135/89 mm Hg; BMI 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum potassium 4.0 mEq/L; LDL cholesterol 200 mg/dL; HDL cholesterol 25 mg/dL; and triglycerides 180 mg/dL. Which intervention should the nurse anticipate?

A. A low-calorie regular diet
B. A statin antilipidemic medication
C. A thiazide diuretic medication
D. Low-salt, low-saturated-fat, low-potassium diet

Correct Answer: B

Rationale: A statin antilipidemic should be prescribed to manage the client’s hypercholesterolemia. It will lower the LDL cholesterol and triglycerides and increase the HDL cholesterol. A low-calorie diet is unnecessary with a normal BMI, a diuretic is not indicated for slightly elevated BP, and a low-potassium diet is not needed with normal potassium levels.

The nurse is completing a home visit with the client who has an arterial ulcer secondary to PAD. Which statement by the client warrants immediate intervention by the nurse?

A. “I soak my feet daily to warm them and keep them soft.”
B. “I cover the sore on my foot with sterile gauze to protect it.”
C. “I use a pillow under my calves to keep my heels off the bed.”
D. “I lubricate my feet daily to prevent them from cracking.”

Correct Answer: A

Rationale: The nurse should immediately intervene when the client states soaking feet daily; foot soaks when the client has PAD can cause maceration (tissue breakdown). Covering with gauze, using a pillow, and lubricating are appropriate actions.