Nokea
The nurse obtains the client’s cardiac monitor print-out illustrated. What should be the nurse’s interpretation of the client’s rhythm?
- A. Atrial flutter
- B. Atrial fibrillation
- C. Sinus bradycardia
- D. Sinus rhythm with premature atrial contractions (PACs)
Correct Answer: C
Rationale: Sinus bradycardia is a regular rhythm with a ventricular rate less than 60 bpm and one discernable P wave prior to each QRS. Atrial flutter and fibrillation have multiple or nondiscernible P waves, and PACs include premature atrial beats, which are not described in the image.
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The client’s BP is being taken at a screening clinic. Which client statement to the nurse demonstrates awareness of having a risk factor for hypertension?
- A. “My doctor told me my body mass index is 23 and my blood pressure is 118/70.”
- B. “I usually have a glass of wine to unwind when I come home from work.”
- C. “I plan to get my blood pressure checked more often, as I am African American.”
- D. “I have colds during the winter, so I plan to get the influenza vaccine every year.”
Correct Answer: C
Rationale: Being African American is a known risk factor for hypertension. Starting to have the BP taken more often demonstrates awareness of having a risk factor for hypertension. A BMI of 23 is normal, excessive alcohol intake increases risk but one glass is not excessive, and colds or flu vaccines do not directly relate to hypertension risk.
The nurse is giving discharge teaching to the client following aortic valve replacement surgery with a synthetic valve. The nurse evaluates that the client understands the teaching when the client states plans to take which action? Select all that apply.
- A. Use a soft toothbrush for dental hygiene.
- B. Floss teeth daily to prevent plaque.
- C. Wear loose-fitting T-shirts or tops.
- D. Use an electric razor for shaving.
- E. Consume foods high in vitamin K.
Correct Answer: A;C;D
Rationale: The client understands when stating: A) Using a soft toothbrush to reduce bleeding risk on anticoagulants; C) Wearing loose-fitting clothing to avoid incision friction; D) Using an electric razor to prevent cuts. Flossing (B) increases bleeding and endocarditis risk, and high vitamin K (E) antagonizes anticoagulants.
The nurse is assessing the client who underwent repair of an aortic aneurysm with graft placement 30 minutes ago. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. What should be the nurse’s priority?
- A. Recheck the pulse in 5 minutes.
- B. Reposition the affected leg.
- C. Notify the surgeon of the finding.
- D. Document that the pulse is absent.
Correct Answer: C
Rationale: The nurse should notify the surgeon immediately to reassess the client. The loss of the pulse could signify graft occlusion or embolization. Rechecking, repositioning, or documenting delays critical intervention.
The nurse collects the following assessment data on the client who has no known health problems: BP 135/89 mm Hg; BMI 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum potassium 4.0 mEq/L; LDL cholesterol 200 mg/dL; HDL cholesterol 25 mg/dL; and triglycerides 180 mg/dL. Which intervention should the nurse anticipate?
- A. A low-calorie regular diet
- B. A statin antilipidemic medication
- C. A thiazide diuretic medication
- D. Low-salt, low-saturated-fat, low-potassium diet
Correct Answer: B
Rationale: A statin antilipidemic should be prescribed to manage the client’s hypercholesterolemia. It will lower the LDL cholesterol and triglycerides and increase the HDL cholesterol. A low-calorie diet is unnecessary with a normal BMI, a diuretic is not indicated for slightly elevated BP, and a low-potassium diet is not needed with normal potassium levels.
The nurse is assessing the client. At which area should the nurse place the stethoscope to best auscultate the client’s murmur associated with mitral regurgitation?
- A. Line A
- B. Line B
- C. Line C
- D. Line D
Correct Answer: D
Rationale: Mitral regurgitation is heard at the location of the mitral valve (line D) and should be auscultated with the bell of the stethoscope at the fifth intercostal space, left midclavicular line. The bell is used to auscultate low-pitched sounds. Lines A, B, and C correspond to aortic, pulmonic, and tricuspid valves, respectively.