Nokea
Which complication should the nurse monitor for in a client with valvular heart disease?
- A. Pulmonary embolism
- B. Heart failure
- C. Liver failure
- D. Pneumonia
Correct Answer: B
Rationale: Valvular heart disease can lead to heart failure due to increased cardiac workload and impaired pump function.
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The nurse is teaching a client about home blood pressure monitoring. Which instruction is most important?
- A. Take your blood pressure at the same time each day.
- B. Use a wrist cuff for the most accurate readings.
- C. Sit with your legs crossed during measurement.
- D. Check your blood pressure only when you feel ill.
Correct Answer: A
Rationale: Consistency in timing ensures accurate trending of blood pressure readings.
The client with pericarditis asks why they hear a rubbing sound. What is the best response?
- A. It's caused by fluid in your lungs.
- B. It's due to inflammation of the heart's lining.
- C. It's a normal heart sound.
- D. It's from high blood pressure.
Correct Answer: B
Rationale: A pericardial friction rub is caused by inflamed pericardial layers rubbing together.
The nurse is discussing discharge teaching with the client who is three (3) days postoperative abdominal aortic aneurysm repair. Which discharge instructions should the nurse include when teaching the client?
- A. Notify the HCP of any redness or irritation of the incision.
- B. Do not lift anything that weighs more than 20 pounds.
- C. Inform the client there may be pain not relieved with pain medication.
- D. Stress the importance of having daily bowel movements.
Correct Answer: A,B
Rationale: Notifying HCP of redness (A) and limiting lifting to <20 lbs (B) prevent infection and graft stress. Unrelieved pain (C) requires evaluation, and daily BMs (D) are not critical.
The nurse is preparing a client for cardioversion. Which instruction is most important?
- A. You will be awake during the procedure.
- B. You must not eat for 4 hours after.
- C. You will receive sedation before the procedure.
- D. You can resume normal activity immediately.
Correct Answer: C
Rationale: Sedation is used during cardioversion to ensure comfort and amnesia during the procedure.
Which instruction should the nurse include when providing discharge instructions to a client diagnosed with peripheral arterial disease?
- A. Encourage the client to use a heating pad on the lower extremities.
- B. Demonstrate to the client the correct way to apply elastic support hose.
- C. Instruct the client to walk daily for at least 30 minutes.
- D. Tell the client to check both feet for red areas at least once a week.
Correct Answer: C
Rationale: Daily walking for 30 minutes (C) promotes collateral circulation in PAD. Heating pads (A) risk burns, elastic hose (B) are for venous disease, and weekly checks (D) are insufficient (daily needed).