Nokea
Which assessment finding in a client with heart failure indicates pulmonary edema?
- A. Crackles in the lung bases
- B. Dry, nonproductive cough
- C. Bradycardia
- D. Warm, dry skin
Correct Answer: A
Rationale: Crackles in the lung bases indicate fluid in the alveoli, a hallmark of pulmonary edema.
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Which client would be most at risk for developing varicose veins?
- A. A Caucasian female who is a nurse.
- B. An African American male who is a bus driver.
- C. An Asian female with no children.
- D. An elderly male with diabetes.
Correct Answer: A
Rationale: Nurses (A) stand for long periods, increasing varicose vein risk. Bus drivers (B) sit, nulliparity (C) is less risky, and diabetes (D) is not a direct factor.
The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?
- A. The client's BP is 110/70.
- B. The client's potassium level is 3.4 mEq/L.
- C. The client has a barky cough.
- D. The client's apical pulse is 56.
Correct Answer: D
Rationale: Beta blockers slow heart rate; an apical pulse of 56 (D) may indicate bradycardia, warranting caution. BP 110/70 (A) is acceptable, K+ 3.4 (B) is low but unrelated, and cough (C) is not a contraindication.
Which dietary selection indicates the client with essential hypertension understands the discharge teaching?
- A. Fried pork chops, a loaded baked potato, and coffee.
- B. Spaghetti and meatballs, garlic bread, and iced tea.
- C. Baked ham, macaroni and cheese, and milk.
- D. Broiled fish, steamed broccoli, and garden salad.
Correct Answer: D
Rationale: Broiled fish, steamed broccoli, and salad (D) are low-sodium, low-fat, aligning with hypertension teaching. Pork chops (A), meatballs/bread (B), and ham/cheese (C) are high-sodium/fat.
Which dietary recommendation should the nurse provide to a client with coronary artery disease?
- A. Eat foods high in saturated fats.
- B. Limit intake of fruits and vegetables.
- C. Choose lean proteins and whole grains.
- D. Increase consumption of sugary drinks.
Correct Answer: C
Rationale: Lean proteins and whole grains reduce cholesterol and improve heart health.
The nurse is demonstrating the use of a blood pressure sphygmomanometer to a client newly diagnosed with hypertension. Which should the nurse teach the client? Select all that apply.
- A. Tell the client to make sure the cuff is placed over an artery.
- B. Teach the client to notify the health-care provider if the BP is >160/100.
- C. Instruct the client about orthostatic hypotension.
- D. Encourage the client to keep a record of the blood pressure readings.
- E. Explain that even when the blood pressure is within normal limits the medication should still be taken.
Correct Answer: A,B,C,D,E
Rationale: Cuff over artery (A), notifying HCP for BP >160/100 (B), orthostatic precautions (C), BP log (D), and continuing meds (E) ensure proper BP management. All apply.