Nokea
The nurse is monitoring a client with atrial fibrillation. Which finding is most concerning?
- A. Heart rate of 110 beats per minute
- B. Blood pressure of 140/90 mmHg
- C. Dizziness and shortness of breath
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Dizziness and shortness of breath suggest hemodynamic instability, which is concerning in atrial fibrillation.
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The nurse is teaching a client with endocarditis about preventing recurrence. Which statement is most important?
- A. You need antibiotics before dental procedures.
- B. You should avoid all vaccinations.
- C. You can stop antibiotics if you feel better.
- D. You should limit fluid intake.
Correct Answer: A
Rationale: Prophylactic antibiotics before dental procedures prevent bacterial seeding of heart valves.
Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy?
- A. Walk 15 to 20 minutes three (3) times a day.
- B. Keep the legs in the dependent position when sitting.
- C. Remove compression bandages before going to bed.
- D. Perform Buerger-Allen exercises four (4) times a day.
Correct Answer: A
Rationale: Walking 15–20 minutes 3×/day (A) promotes venous return post-sclerotherapy. Dependent position (B) worsens pooling, bandages (C) stay on, and Buerger-Allen (D) is for arterial disease.
The client asks the nurse, 'My doctor just told me that atherosclerosis is why my legs hurt when I walk. What does that mean?' Which response by the nurse would be the best response?
- A. The muscle fibers and endothelial lining of your arteries have become thickened.'
- B. The next time you see your HCP, ask what atherosclerosis means.'
- C. The valves in the veins of your legs are incompetent so your legs hurt.'
- D. You have a hardening of your arteries that decreases the oxygen to your legs.'
Correct Answer: D
Rationale: Atherosclerosis causes arterial hardening, reducing leg oxygen (D), a clear explanation for claudication. Thickening (A) is technical, deferring (B) avoids teaching, and venous valves (C) are unrelated.
The client with heart failure reports fatigue. Which action should the nurse take first?
- A. Encourage bedrest all day.
- B. Assess oxygen saturation.
- C. Administer a diuretic.
- D. Increase fluid intake.
Correct Answer: B
Rationale: Fatigue in heart failure may indicate hypoxemia, so assessing oxygen saturation is the priority.
Which medical treatment would be prescribed for the client with an AAA less than 3 cm?
- A. Ultrasound every six (6) months.
- B. Intravenous pyelogram yearly.
- C. Assessment of abdominal girth monthly.
- D. Repair of abdominal aortic aneurysm.
Correct Answer: A
Rationale: Small AAAs (<3 cm) are monitored with ultrasound every 6 months (A). IV pyelogram (B) is irrelevant, girth (C) is not standard, and repair (D) is for larger AAAs (>5.5 cm).