Nokea
The nurse is teaching a class to clients diagnosed with hypertension. Which should the nurse teach the clients?
- A. The blood pressure target range should be 120/80.
- B. Take the medication even when feeling well.
- C. Get up quickly when rising from a recumbent position.
- D. Consume a 3,000-mg sodium diet.
Correct Answer: B
Rationale: Hypertension requires lifelong medication, even when asymptomatic (B). Target BP (A) is <130/80, rapid rising (C) risks orthostasis, and 3,000 mg sodium (D) is too high (aim <2,000 mg).
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Which finding in a client with mitral stenosis requires immediate action?
- A. Heart rate of 100 beats per minute
- B. New onset of atrial fibrillation
- C. Blood pressure of 140/90 mmHg
- D. Mild fatigue
Correct Answer: B
Rationale: New-onset atrial fibrillation increases the risk of thromboembolism in mitral stenosis, requiring immediate intervention.
The client diagnosed with Buerger’s disease (thromboangiitis obliterans) asks the nurse, 'What is the worst thing that could happen if I don’t quit smoking? I love my cigarettes.' Which statement is the nurse’s best response?
- A. You are concerned about quitting smoking. Let’s sit down and talk about it.'
- B. Many clients end up having to have an amputation, especially a leg.'
- C. You should consider attending a smoking cessation program.'
- D. Your coronary arteries could block and cause a heart attack.'
Correct Answer: B
Rationale: Smoking worsens Buerger’s, risking severe ischemia and amputation (B). Concern (A) avoids the question, cessation programs (C) are secondary, and heart attack (D) is less specific.
The client with heart failure asks why they need to limit sodium intake. What is the best response?
- A. Sodium causes your heart to beat faster.
- B. Sodium makes your body retain fluid.
- C. Sodium increases your blood sugar.
- D. Sodium weakens your heart muscle.
Correct Answer: B
Rationale: Sodium promotes fluid retention, which increases cardiac workload in heart failure.
Which assessment data would warrant immediate intervention by the nurse?
- A. The client diagnosed with DVT who complains of pain on inspiration.
- B. The immobile client who has refused to turn for the last three (3) hours.
- C. The client who had an open cholecystectomy who refuses to breathe deeply.
- D. The client who has had an inguinal hernia repair who must void before discharge.
Correct Answer: A
Rationale: Pain on inspiration in DVT (A) suggests pulmonary embolism, requiring immediate action. Immobility (B), shallow breathing (C), and voiding (D) are less urgent.
The nurse and an unlicensed assistive personnel (UAP) are caring for a 64-year-old client who is four (4) hours postoperative bilateral femoral-popliteal bypass surgery. Which nursing task should be delegated to the UAP?
- A. Monitor the continuous passive motion machine.
- B. Assist the client to the bedside commode.
- C. Feed the client the evening meal.
- D. Elevate the foot of the client's bed.
Correct Answer: C
Rationale: Feeding the client (C) is within the UAP’s scope and safe post-bypass. Monitoring CPM (A), assisting to commode (B), and elevating bed (D) require nursing judgment due to circulation concerns.