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Which activity should the nurse encourage for a client with heart failure?
- A. Walking at a slow pace daily.
- B. Lifting heavy weights.
- C. Running for 30 minutes daily.
- D. Remaining on bedrest.
Correct Answer: A
Rationale: Low-intensity exercise like walking improves cardiovascular fitness without overstraining the heart.
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The client is diagnosed with a small abdominal aortic aneurysm. Which interventions should be included in the discharge teaching? Select all that apply.
- A. Tell the client to exercise three (3) times a week for 30 minutes.
- B. Encourage the client to eat a low-fat, low-cholesterol diet.
- C. Instruct the client to decrease tobacco use.
- D. Discuss the importance of losing weight with the client.
- E. Teach the client to wear a truss at all times.
Correct Answer: A,B,C,D
Rationale: Exercise (A), low-fat diet (B), smoking reduction (C), and weight loss (D) reduce AAA progression. Trusses (E) are irrelevant to AAA management.
The client admitted with a diagnosis of pneumonia complains of tenderness and pain in the left calf, and the nurse assesses a positive Homans’ sign. Which interventions should the nurse implement? List in order of priority.
- A. Notify the health-care provider.
- B. Initiate an intravenous line.
- C. Monitor the client’s PTT.
- D. Administer a continuous heparin infusion.
- E. Instruct the client not to get out of the bed.
Correct Answer: A,E,B,D,C
Rationale: 1. Notify HCP (A): Calf pain and positive Homans’ suggest DVT, requiring urgent evaluation. 2. Instruct bedrest (E): Prevents clot dislodgement. 3. Initiate IV (B): Prepares for heparin. 4. Administer heparin (D): Treats DVT post-order. 5. Monitor PTT (C): Ensures therapeutic heparin levels.
The nurse is teaching the client with peripheral vascular disease. Which interventions should the nurse discuss with the client? Select all that apply.
- A. Wash your feet in antimicrobial soap.
- B. Wear comfortable, well-fitting shoes.
- C. Cut your toenails in an arch.
- D. Keep the area between the toes dry.
- E. Use a heating pad when feet are cold.
Correct Answer: B,D
Rationale: Well-fitting shoes (B) prevent injury, and dry toes (D) prevent infection in PVD. Antimicrobial soap (A) is unnecessary, arched toenails (C) risk ingrown nails, and heating pads (E) risk burns.
The health-care provider prescribes an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with essential hypertension. Which statement is the most appropriate rationale for administering this medication?
- A. ACE inhibitors prevent beta receptor stimulation in the heart.
- B. This medication blocks the alpha receptors in the vascular smooth muscle.
- C. ACE inhibitors prevent vasoconstriction and sodium and water retention.
- D. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle.
Correct Answer: C
Rationale: ACE inhibitors block angiotensin II, preventing vasoconstriction and sodium/water retention (C), thus lowering BP. Beta (A) and alpha (B) receptors are unrelated, and smooth muscle relaxation (D) is a secondary effect.
Which diagnostic test should the nurse expect for a client with suspected pericarditis?
- A. Electrocardiogram (ECG)
- B. Complete blood count (CBC)
- C. D-dimer test
- D. Chest X-ray
Correct Answer: A
Rationale: An ECG can show characteristic ST-segment elevation in pericarditis due to pericardial inflammation.