Nokea
The nurse is teaching a client about home blood pressure monitoring. Which instruction is most important?
- A. Take your blood pressure at the same time each day.
- B. Use a wrist cuff for the most accurate readings.
- C. Sit with your legs crossed during measurement.
- D. Check your blood pressure only when you feel ill.
Correct Answer: A
Rationale: Consistency in timing ensures accurate trending of blood pressure readings.
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The nurse is preparing a client for cardioversion. Which instruction is most important?
- A. You will be awake during the procedure.
- B. You must not eat for 4 hours after.
- C. You will receive sedation before the procedure.
- D. You can resume normal activity immediately.
Correct Answer: C
Rationale: Sedation is used during cardioversion to ensure comfort and amnesia during the procedure.
Which complaint made by the client to the nurse can best be attributed to varicose leg veins?
- A. My legs and feet feel tired after prolonged standing.
- B. My feet perspire heavily during the day.
- C. I wake up at night with a restless feeling in my legs.
- D. I have pain in my shins when I jog.
Correct Answer: A
Rationale: Varicose veins often cause fatigue and heaviness in the legs, especially after prolonged standing, due to impaired venous return.
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.
The client with heart failure is prescribed digoxin. Which finding should the nurse report immediately?
- A. Heart rate of 58 beats per minute
- B. Potassium level of 3.2 mEq/L
- C. Blood pressure of 130/85 mmHg
- D. Respiratory rate of 18 breaths per minute
Correct Answer: B
Rationale: Hypokalemia (low potassium) increases the risk of digoxin toxicity, requiring immediate reporting.
The nurse is demonstrating the use of a blood pressure sphygmomanometer to a client newly diagnosed with hypertension. Which should the nurse teach the client? Select all that apply.
- A. Tell the client to make sure the cuff is placed over an artery.
- B. Teach the client to notify the health-care provider if the BP is >160/100.
- C. Instruct the client about orthostatic hypotension.
- D. Encourage the client to keep a record of the blood pressure readings.
- E. Explain that even when the blood pressure is within normal limits the medication should still be taken.
Correct Answer: A,B,C,D,E
Rationale: Cuff over artery (A), notifying HCP for BP >160/100 (B), orthostatic precautions (C), BP log (D), and continuing meds (E) ensure proper BP management. All apply.