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The nurse just received the a.m. shift report. Which client should the nurse assess first?
- A. The client diagnosed with coronary artery disease who has a BP of 170/100.
- B. The client diagnosed with DVT who is complaining of chest pain.
- C. The client diagnosed with pneumonia who has a pulse oximeter reading of 98%.
- D. The client diagnosed with ulcerative colitis who has non-bloody diarrhea.
Correct Answer: B
Rationale: Chest pain in DVT (B) suggests pulmonary embolism, a life-threatening emergency. Hypertension (A) is urgent but less immediate, SpO2 98% (C) is normal, and diarrhea (D) is non-emergent.
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The HCP prescribes an HMG-CoA reductase inhibitor (statin) medication to a client with CAD. Which should the nurse teach the client about this medication?
- A. Take this medication on an empty stomach.
- B. This medication should be taken in the evening.
- C. Do not be concerned if muscle pain occurs.
- D. Check your cholesterol level daily.
Correct Answer: B
Rationale: Statins are most effective in the evening (B) due to cholesterol synthesis peaking at night. Food (A) enhances absorption, muscle pain (C) requires reporting, and daily checks (D) are unnecessary.
The nurse is assessing a client with dilated cardiomyopathy. Which finding is expected?
- A. Jugular vein distension
- B. Hypertension
- C. Dry skin
- D. Tachypnea
Correct Answer: A
Rationale: Dilated cardiomyopathy causes reduced cardiac output, leading to jugular vein distension from fluid backup.
The nurse is teaching a class on arterial essential hypertension. Which modifiable risk factors would the nurse include when preparing this presentation?
- A. Include information on retinopathy and nephropathy.
- B. Discuss sedentary lifestyle and smoking cessation.
- C. Include discussions on family history and gender.
- D. Provide information on a low-fiber and high-salt diet.
Correct Answer: B
Rationale: Modifiable risk factors for hypertension include sedentary lifestyle and smoking (B), which can be changed. Retinopathy/nephropathy (A) are complications, family history/gender (C) are non-modifiable, and low-fiber/high-salt (D) promotes hypertension.
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.
The nurse is caring for a client diagnosed with deep vein thrombosis. Which information reported to the nurse by the unlicensed assistive personnel (UAP) requires immediate intervention?
- A. The UAP informed the nurse the client is complaining of chest pain.
- B. The UAP notified the nurse the client’s blood pressure is 100/66.
- C. The UAP reported the client is requesting to be able to take a shower.
- D. The UAP tells the nurse the client is asking for medication for a headache.
Correct Answer: A
Rationale: Chest pain in DVT (A) suggests pulmonary embolism, requiring immediate intervention. Hypotension (B), showering (C), and headache (D) are less urgent.