Nokea
The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning?
- A. Cholesterol: 126 mg/dL
- B. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL
- C. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL
- D. Triglycerides: 198 mg/dL
Correct Answer: D
Rationale: Triglycerides in men should be below 160 mg/dL. The other values are within acceptable ranges for adult males.
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A nurse is caring for a client who weighs 207 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your answer using a whole number.) __ mg
- A. 90
- B. 80
- C. 100
- D. 70
Correct Answer: A
Rationale: The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 207 pounds (94 kg), so the nurse anticipates administering the maximum dose of 90 mg.
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
- A. Do you have trouble affording your medications?
- B. Most people with hypertension do not have symptoms
- C. Most people get severe morning headaches
- D. You need to take your medicine or you will get kidney failure
Correct Answer: A
Rationale: Most people with hypertension are asymptomatic, although a small percentage do have symptoms. Since the client has already admitted nonadherence, assessing barriers such as affordability is the most effective response to improve compliance.
A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse?
- A. Administer oxygen via non-rebreather mask
- B. Ensure the client has a patent airway
- C. Prepare to assist with suturing the artery
- D. Start two large-bore IVs with normal saline
Correct Answer: B
Rationale: Airway always takes priority, followed by breathing and circulation. Ensuring a patent airway is the first step before other interventions.
A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)
- A. Administer pain medication
- B. Assess distal pulses every 10 minutes
- C. Have the client sign a surgical consent
- D. Notify the Rapid Response Team
- E. Take vital signs every 10 minutes
Correct Answer: B,D,E
Rationale: This client may have a rupturing aneurysm. The nurse should notify the Rapid Response Team and perform frequent assessments of pulses and vital signs. Pain medication could lower blood pressure further, and consent should be handled after the physician explains the procedure.
A client with peripheral artery disease (PAD) makes the following statements to the nurse. Which indicates the need for further teaching?
- A. I should avoid using heating pads on my legs
- B. I need to walk until I feel pain, then rest
- C. I should keep my legs elevated when resting
- D. It's going to be really hard but I will stop smoking
Correct Answer: A
Rationale: Clients with PAD should avoid heating pads due to decreased skin sensitivity, which can lead to burns. This statement shows understanding, so no further teaching is needed for it. The other statements align with proper PAD management.