Nokea
The nurse is teaching the client recently diagnosed with essential hypertension. Which instruction should the nurse provide when discussing heart healthy exercise?
- A. Walk at least 30 minutes a day on flat surfaces.
- B. Perform light weight lifting three (3) times a week.
- C. Recommend high-intensity aerobics daily.
- D. Encourage the client to swim laps once a week.
Correct Answer: A
Rationale: Walking 30 minutes daily (A) is aerobic, safe, and effective for hypertension. Light weight lifting (B) is less ideal, high-intensity aerobics (C) is too strenuous, and weekly swimming (D) is insufficient.
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Which health-care provider’s order should the nurse question in a client diagnosed with an expanding abdominal aortic aneurysm who is scheduled for surgery in the morning?
- A. Type and crossmatch for two (2) units of blood.
- B. Tap water enema until clear fecal return.
- C. Bedrest with bathroom privileges.
- D. Keep nothing by mouth (NPO) after midnight.
Correct Answer: B
Rationale: Enemas (B) risk increasing intra-abdominal pressure, dangerous in expanding AAA. Blood crossmatch (A), bedrest (C), and NPO (D) are appropriate pre-surgery.
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 complication of anticoagulant therapy should the nurse teach the client to report to the health-care provider?
- A. Gastric upset.
- B. Bleeding from any site.
- C. Constipation.
- D. Myocardial infarction.
Correct Answer: B
Rationale: Bleeding (B) is a serious anticoagulant complication, requiring HCP notification. Gastric upset (A) and constipation (C) are minor, and MI (D) is unrelated.
Which interventions should the nurse discuss with the client diagnosed with atherosclerosis? Select all that apply.
- A. Include the significant other in the discussion.
- B. Stop smoking or using any type of tobacco products.
- C. Maintain a sedentary lifestyle as much as possible.
- D. Avoid stressful situations.
- E. Daily isometric exercises are important.
Correct Answer: A,B,D
Rationale: Including significant other (A), stopping smoking (B), and avoiding stress (D) reduce atherosclerosis risk. Sedentary lifestyle (C) worsens it, and isometric exercises (E) increase BP.
The nurse is completing a neurovascular assessment on the client with chronic venous insufficiency. What should be included in this assessment? Select all that apply.
- A. Assess for paresthesia.
- B. Assess for pedal pulses.
- C. Assess for paralysis.
- D. Assess for pallor.
- E. Assess for polar (temperature).
Correct Answer: A,B
Rationale: Paresthesia (A) and pedal pulses (B) assess neurovascular status in venous insufficiency. Paralysis (C) and pallor (D) are arterial, and polar/temperature (E) is assessed but not primary.