Nokea
Which assessment finding in a client with a pacemaker requires immediate action? Select all that apply.
- A. Heart rate of 50 beats per minute
- B. Pain at the insertion site
- C. Fever of 101°F
- D. Hiccups that persist
- E. Swelling at the pacemaker site
- F. Mild bruising at the site
Correct Answer: A,C,D,E
Rationale: Low heart rate, fever, persistent hiccups, and swelling suggest pacemaker malfunction or infection, requiring immediate attention.
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The client with hypertension asks why they need to limit stress. What is the best response?
- A. Stress causes fluid retention.
- B. Stress increases your heart rate and blood pressure.
- C. Stress reduces oxygen to your heart.
- D. Stress weakens your immune system.
Correct Answer: B
Rationale: Stress activates the sympathetic nervous system, increasing heart rate and blood pressure.
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 monitoring a client post-percutaneous coronary intervention (PCI). Which finding requires immediate action?
- A. Heart rate of 80 beats per minute
- B. Bleeding at the catheter site
- C. Blood pressure of 130/85 mmHg
- D. Mild discomfort at the insertion site
Correct Answer: B
Rationale: Bleeding at the catheter site can indicate a hematoma or hemorrhage, requiring immediate intervention.
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 nurse is caring for clients on a telemetry floor. Which nursing task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)?
- A. Teach the client how to perform a glucometer check.
- B. Assist feeding the client diagnosed with congestive heart failure.
- C. Check the cholesterol level for the client diagnosed with atherosclerosis.
- D. Assist the nurse to check the unit of blood at the client's bedside.
Correct Answer: B
Rationale: Feeding a CHF client (B) is within UAP scope and safe. Teaching glucometer (A), checking cholesterol (C), and blood verification (D) require nursing judgment.