Nokea
The nurse is planning care for a client admitted with infective endocarditis (IE). Which assessment finding would indicate that the client is experiencing a complication?
- A. petechial rashes
- B. flank pain
- C. headache
- D. fever
Correct Answer: B
Rationale: Flank pain may indicate renal embolism, a complication of infective endocarditis due to septic emboli.
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What is the correct documentation of the patient's peripheral pulse when the finding is that the posterior tibial pulse is weak and thready?
- A. Grade C posterior tibial pulse
- B. Posterior tibial pulse is Grade B
- C. The client's posterior tibial is 2
- D. Posterior tibial pulse is 1
Correct Answer: D
Rationale: A weak and thready pulse is documented as a 1+ on a 0-4 scale, where 1 indicates a barely palpable pulse.
The nurse is caring for a client in the emergency department, reporting a headache and generalized flushing. The nurse should request a prescription for which medication? See the exhibit for additional client information.
- A. enalapril
- B. labetalol
- C. amiodarone
- D. nitroglycerin
Correct Answer: B
Rationale: Headache and flushing in a hypertensive crisis suggest the need for labetalol, a beta-blocker, to control blood pressure.
Which of the following statements should the nurse include when teaching a community health course on adult cardiopulmonary resuscitation (CPR)? Select all that apply.
- A. The compression rate is 100 to 120 per minute.
- B. The compression depth should be 1.5 inches.
- C. Allow full chest recoil between compressions.
- D. Rotate compressor at least every 2 minutes.
- E. Stop to check your pulse every 30 seconds.
Correct Answer: A,C,D
Rationale: Compression rate of 100-120/min ensures adequate circulation. B: Incorrect - Depth should be 2-2.4 inches in adults. C: Correct - Full chest recoil maximizes venous return. D: Correct - Rotating compressors prevents fatigue. E: Incorrect - Pulse checks are done after rhythm checks, not every 30 seconds.
The nurse is visiting a client who was recently prescribed antihypertensive medications. Which statement, if made by the client, requires follow-up?
- A. My pulse decreases after taking my metoprolol.
- B. I started taking my furosemide right before I went to sleep.
- C. I am seasoning my foods with salt substitutes while taking my hydrochlorothiazide.
- D. I wear my clonidine patch for seven days.
Correct Answer: B
Rationale: Taking furosemide, a diuretic, at bedtime can cause nocturia, disrupting sleep and increasing fall risk. It should be taken earlier.
The nurse is teaching a group of clients about varicose veins and home care management. Which of the following should the nurse include in the teaching session?
- A. When you are sitting, keep your legs lower than your heart
- B. Wear compression stockings during the day
- C. Participate in activities that have you stand for long periods
- D. Take a low-dose aspirin to prevent the development of new varicose veins
Correct Answer: B
Rationale: Compression stockings reduce venous pooling and improve circulation, a key management strategy for varicose veins.