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The nurse is teaching a client about heart failure medications. Which statement about furosemide (Lasix) is accurate?
- A. It strengthens your heart muscle.
- B. It lowers your blood pressure.
- C. It helps remove excess fluid.
- D. It prevents irregular heartbeats.
Correct Answer: C
Rationale: Furosemide is a loop diuretic that promotes fluid excretion, reducing preload in heart failure.
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The nurse is teaching the client diagnosed with deep vein thrombosis and prescribed warfarin. Which should the nurse teach the client? Select all that apply.
- A. Keep a constant amount of green, leafy vegetables in the diet.
- B. Instruct the client to have regular INR laboratory work done.
- C. Tell the client to go to the hospital immediately for any bleeding.
- D. Inform the client to notify the HCP if having dark, tarry stools.
- E. Encourage the client to avoid all green vegetables.
- F. Have the client take iron orally to prevent bleeding.
Correct Answer: A,B,D
Rationale: Constant green vegetable intake (A), regular INR (B), and reporting tarry stools (D) ensure safe warfarin use. Avoiding all greens (E) is unnecessary, and iron (C) doesn’t prevent bleeding. Immediate hospital for any bleeding (C) is excessive; minor bleeding requires HCP contact.
As the nurse provides discharge instructions to the client with varicose veins, which activity should the nurse suggest the client avoid?
- A. Walking in athletic shoes.
- B. Jogging a mile a day.
- C. Sitting with crossed knees.
- D. Wearing wool socks.
Correct Answer: C
Rationale: Sitting with crossed knees can compress veins, worsening venous stasis in clients with varicose veins.
The nurse is teaching a class on atherosclerosis. Which statement describes the scientific rationale as to why diabetes is a risk factor for developing atherosclerosis?
- A. Glucose combines with carbon monoxide, instead of with oxygen, and this leads to oxygen deprivation of tissues.
- B. Diabetes stimulates the sympathetic nervous system, resulting in peripheral constriction that increases the development of atherosclerosis.
- C. Diabetes speeds the atherosclerotic process by thickening the basement membrane of both large and small vessels.
- D. The increased glucose combines with the hemoglobin, which causes deposits of plaque in the lining of the vessels.
Correct Answer: C
Rationale: Diabetes accelerates atherosclerosis by thickening vascular basement membranes (C), promoting plaque. Carbon monoxide (A), sympathetic stimulation (B), and glucose-hemoglobin (D) are incorrect mechanisms.
The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply.
- A. Place sequential compression devices on both legs.
- B. Instruct the client to stay in bed and not ambulate.
- C. Encourage fluids and a diet high in roughage.
- D. Monitor IV site every four (4) hours and prn.
- E. Assess Homans’ sign every 24 hours.
Correct Answer: A,C,D
Rationale: Compression devices (A), fluids/fiber (C), and IV monitoring (D) prevent DVT progression and complications. Bedrest (B) is not absolute (early ambulation is encouraged), and Homans’ sign (E) is unreliable.
Which instruction should the nurse include for a client with heart failure to monitor fluid status?
- A. Check blood pressure twice daily.
- B. Weigh yourself every morning.
- C. Record urine color daily.
- D. Measure abdominal girth weekly.
Correct Answer: B
Rationale: Daily weight monitoring detects fluid retention early, as 1 liter of fluid equals approximately 2.2 pounds.