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The nurse is monitoring a client post-percutaneous coronary intervention (PCI). Which finding requires immediate action?
- A. Heart rate of 80 beats per minute
- B. Bleeding at the catheter site
- C. Blood pressure of 130/85 mmHg
- D. Mild discomfort at the insertion site
Correct Answer: B
Rationale: Bleeding at the catheter site can indicate a hematoma or hemorrhage, requiring immediate intervention.
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Which activity should the nurse encourage for a client with heart failure?
- A. Walking at a slow pace daily.
- B. Lifting heavy weights.
- C. Running for 30 minutes daily.
- D. Remaining on bedrest.
Correct Answer: A
Rationale: Low-intensity exercise like walking improves cardiovascular fitness without overstraining the heart.
Which intervention should the nurse include in the plan of care for a client with pericarditis? Select all that apply.
- A. Monitor for signs of cardiac tamponade.
- B. Administer anti-inflammatory medications.
- C. Encourage deep breathing exercises.
- D. Elevate the head of the bed.
- E. Restrict all physical activity.
- F. Check vital signs every 8 hours.
Correct Answer: A,B,D,E
Rationale: Monitoring for tamponade, administering anti-inflammatories, elevating the bed, and restricting activity manage pericarditis effectively.
Which nursing instruction is most beneficial in helping relieve the client's symptoms caused by varicose veins?
- A. Elevate your legs frequently during the day.
- B. Keep the room temperature above 70°F (21°C).
- C. Massage your calves when experiencing leg cramps.
- D. Modify your lifestyle to include sedentary activities.
Correct Answer: A
Rationale: Elevating the legs promotes venous return, reducing swelling and discomfort associated with varicose veins.
The nurse just received the a.m. shift report. Which client should the nurse assess first?
- A. The client diagnosed with coronary artery disease who has a BP of 170/100.
- B. The client diagnosed with DVT who is complaining of chest pain.
- C. The client diagnosed with pneumonia who has a pulse oximeter reading of 98%.
- D. The client diagnosed with ulcerative colitis who has non-bloody diarrhea.
Correct Answer: B
Rationale: Chest pain in DVT (B) suggests pulmonary embolism, a life-threatening emergency. Hypertension (A) is urgent but less immediate, SpO2 98% (C) is normal, and diarrhea (D) is non-emergent.
Which client would be most likely to develop an abdominal aortic aneurysm?
- A. A 45-year-old female with a history of osteoporosis.
- B. An 80-year-old female with congestive heart failure.
- C. A 69-year-old male with peripheral vascular disease.
- D. A 30-year-old male with a genetic predisposition to AAA.
Correct Answer: C
Rationale: Older males with PVD (C) are at highest risk for AAA due to atherosclerosis. Osteoporosis (A), CHF (B), and young age (D) are lower risk, even with genetics.