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When offered the pain medication, the client says to the nurse, 'If that's Motrin, I don't want it. It makes me sick to my stomach.' What is the most appropriate nursing action at this time?
- A. Tell the client that the drug is ibuprofen.
- B. Explain that the prescribed medication must be taken.
- C. Advise the client to take the drug with plenty of water.
- D. Report the information to the charge nurse.
Correct Answer: D
Rationale: Reporting the client's adverse reaction to the charge nurse ensures proper communication and potential adjustment of the medication plan.
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Which instruction should the nurse include for a client with valvular heart disease?
- A. Avoid high-sodium foods.
- B. Increase caffeine intake.
- C. Limit fluid intake.
- D. Avoid regular exercise.
Correct Answer: A
Rationale: Avoiding high-sodium foods prevents fluid retention, reducing strain on the heart.
Which teaching point should the nurse include for a client with cardiomyopathy? Select all that apply.
- A. Monitor for signs of heart failure.
- B. Avoid alcohol consumption.
- C. Take medications as prescribed.
- D. Engage in high-intensity exercise.
- E. Report sudden weight gain.
- F. Limit fluid intake as advised.
Correct Answer: A,B,C,E,F
Rationale: Monitoring heart failure signs, avoiding alcohol, adhering to medications, reporting weight gain, and limiting fluids prevent complications.
The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse?
- A. The client takes a stool softener every day at dinnertime.
- B. The client is wearing a Medic Alert bracelet.
- C. The client takes vitamin E over-the-counter medication.
- D. The client has purchased a new recliner that will elevate the legs.
Correct Answer: C
Rationale: Vitamin E (C) increases bleeding risk with DVT anticoagulation, requiring intervention. Stool softeners (A), Medic Alert (B), and leg elevation (D) are appropriate.
The client diagnosed with essential hypertension asks the nurse, 'Why do I have high blood pressure?' Which response by the nurse would be most appropriate?
- A. You probably have some type of kidney disease that causes the high BP.'
- B. More than likely you have had a diet high in salt, fat, and cholesterol.'
- C. There is no specific cause for hypertension, but there are many known risk factors.'
- D. You are concerned that you have high blood pressure. Let's sit down and talk.'
Correct Answer: C
Rationale: Essential hypertension has no single cause but multiple risk factors (e.g., genetics, lifestyle) (C). Kidney disease (A) or diet (B) may contribute but aren’t definitive, and concern (D) avoids the question.
The nurse is teaching a client with cardiomyopathy about implantable cardioverter-defibrillators (ICDs). Which statement is accurate?
- A. It will prevent all arrhythmias.
- B. It delivers a shock if a dangerous rhythm occurs.
- C. It replaces the need for medications.
- D. It requires replacement every 2 years.
Correct Answer: B
Rationale: An ICD monitors heart rhythm and delivers a shock to restore normal rhythm in life-threatening arrhythmias.