Nokea
What should be included in the teaching plan for an adult who has hypertension?
- A. Reduce dietary calcium.
- B. Avoid aerobic exercise.
- C. Reduce alcohol intake.
- D. Limit fluid intake.
Correct Answer: C
Rationale: Reducing alcohol intake helps manage hypertension by lowering blood pressure. Calcium reduction, avoiding aerobic exercise, or limiting fluids are not standard recommendations.
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The nurse identifies the concept of tissue perfusion as a client problem. Which is an antecedent of tissue perfusion?
- A. The client has a history of coronary artery disease (CAD).
- B. The client has a history of diabetes insipidus (DI).
- C. The client has a history of chronic obstructive pulmonary disease (COPD).
- D. The client has a history of multiple fractures from a motor-vehicle accident.
Correct Answer: A
Rationale: CAD (A) directly impairs cardiac perfusion due to atherosclerosis, an antecedent to perfusion issues. DI (B), COPD (C), and fractures (D) are less directly related.
The telemetry nurse notes a peaked T wave for the client diagnosed with congestive heart failure. Which laboratory data should the nurse assess?
- A. CK-MB.
- B. Troponin.
- C. BNP.
- D. Potassium.
Correct Answer: D
Rationale: Peaked T waves indicate hyperkalemia; assessing potassium (D) is critical in CHF patients on diuretics. CK-MB (A) and troponin (B) are for MI, BNP (C) for heart failure severity.
The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement?
- A. Restrict the client's fluids as ordered.
- B. Keep the client in the supine position.
- C. Maintain oxygen saturation at 90%.
- D. Monitor the total parenteral nutrition.
Correct Answer: A
Rationale: Fluid restriction (A) prevents overload post-mitral valve surgery. Supine position (B) increases preload, SpO2 90% (C) is too low, and TPN (D) is not routine.
An adult male has a high level of high-density lipoproteins (HDL) in proportion to low-density lipoproteins (LDL). How does this relate to his risk of developing coronary artery disease (CAD)?
- A. His risk for CAD is low.
- B. There is no direct correlation.
- C. His risk may increase with exercise.
- D. His risk will increase with age.
Correct Answer: A
Rationale: A high HDL-to-LDL ratio is protective against coronary artery disease, lowering risk due to HDL’s role in removing cholesterol from arteries.
When the client returns to the room after the percutaneous transluminal coronary angioplasty (PTCA) procedure, which assessment finding should be reported immediately to the physician?
- A. Urine output of 100 mL/hour
- B. Blood pressure of 108/68 mm Hg
- C. Dry mouth
- D. Chest pain
Correct Answer: D
Rationale: Chest pain post-PTCA may indicate re-occlusion or complications like stent thrombosis, requiring immediate reporting.