Nokea
The nurse is teaching a client with endocarditis about preventing recurrence. Which statement is most important?
- A. You need antibiotics before dental procedures.
- B. You should avoid all vaccinations.
- C. You can stop antibiotics if you feel better.
- D. You should limit fluid intake.
Correct Answer: A
Rationale: Prophylactic antibiotics before dental procedures prevent bacterial seeding of heart valves.
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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.
Which instruction should the nurse include when providing discharge instructions to a client diagnosed with peripheral arterial disease?
- A. Encourage the client to use a heating pad on the lower extremities.
- B. Demonstrate to the client the correct way to apply elastic support hose.
- C. Instruct the client to walk daily for at least 30 minutes.
- D. Tell the client to check both feet for red areas at least once a week.
Correct Answer: C
Rationale: Daily walking for 30 minutes (C) promotes collateral circulation in PAD. Heating pads (A) risk burns, elastic hose (B) are for venous disease, and weekly checks (D) are insufficient (daily needed).
The client diagnosed with a deep vein thrombosis is prescribed heparin via continuous infusion. The client's laboratory data are: PT 12.2 aPTT 48 Control 1.4 Control 32 INR 1 Based on the laboratory results, which intervention should the nurse implement?
- A. Request a change of medication to a subcutaneous anticoagulant.
- B. Administer AquaMephyton (vitamin K) IM.
- C. Have the dietary department remove all green, leafy vegetables from the trays.
- D. Administer the IV as ordered.
Correct Answer: D
Rationale: aPTT 48 (therapeutic 1.5–2× control 32 = 48–64) is within range; continue heparin as ordered (D). Subcutaneous (A) is inappropriate, vitamin K (B) reverses heparin, and diet (C) is for warfarin.
Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy?
- A. Walk 15 to 20 minutes three (3) times a day.
- B. Keep the legs in the dependent position when sitting.
- C. Remove compression bandages before going to bed.
- D. Perform Buerger-Allen exercises four (4) times a day.
Correct Answer: A
Rationale: Walking 15–20 minutes 3×/day (A) promotes venous return post-sclerotherapy. Dependent position (B) worsens pooling, bandages (C) stay on, and Buerger-Allen (D) is for arterial disease.
Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease?
- A. An anticoagulant medication.
- B. An antihypertensive medication.
- C. An antiplatelet medication.
- D. A muscle relaxant.
Correct Answer: C
Rationale: Antiplatelet medications (e.g., aspirin, clopidogrel) (C) prevent clot formation in PAD. Anticoagulants (A) are for DVT, antihypertensives (B) for BP, and muscle relaxants (D) are irrelevant.