Nokea
Which factors does the nurse teach as contributing to aneurysm formation? (Select all that apply.)
- A. Atherosclerosis
- B. Down syndrome
- C. Frequent heartburn
- D. History of hypertension
- E. History of smoking
Correct Answer: A,D,E
Rationale: Atherosclerosis, hypertension, and smoking are major risk factors for aneurysm formation. Down syndrome and heartburn are not related.
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A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
- A. African-American churches
- B. Asian-American groceries
- C. High school sports camps
- D. Women's health clinics
Correct Answer: A
Rationale: Providing services at African-American churches has the potential to reach this priority population, as African-Americans are at higher risk for hypertension. While hypertension education is important for all groups, this is the priority population for this intervention.
The nurse is caring for four hypertensive clients. Which drug/laboratory value combination should the nurse report immediately to the health care provider?
- A. Furosemide (Lasix)/potassium 2.1 mEq/L
- B. Hydrochlorothiazide/potassium 3.5 mEq/L
- C. Spironolactone (Aldactone)/potassium 5.1 mEq/L
- D. Losartan/sodium 135 mEq/L
Correct Answer: A
Rationale: Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is critically low and should be reported immediately. A potassium level of 5.1 mEq/L is on the high side but not as critical. The other laboratory values are within normal ranges.
A nurse is caring for a client on IV infusion of heparin. What actions does the nurse include in the client's plan? (Select all that apply.)
- A. Assess the client for bleeding
- B. Monitor the daily activated partial thromboplastin time (aPTT) results
- C. Stop the IV if aPTT shows baseline
- D. Use an IV pump for the infusion
- E. Weigh the client daily on the same scale
Correct Answer: A,B,D
Rationale: Assessing for bleeding, monitoring aPTT, and using an IV pump are critical for heparin safety. Stopping the IV at baseline aPTT is incorrect, as therapeutic levels are 1.5-2 times baseline. Weighing is not directly related.
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding indicates a priority outcome for this client has been met?
- A. Pain rated as 2/10 after medication
- B. Distal pulse on affected extremity 2+/4
- C. Client remains on bedrest as directed
- D. Verifies understanding of procedure
Correct Answer: B
Rationale: Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4 indicates good perfusion, meeting a priority outcome. The other options are important but secondary to circulation.
A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the diagnosis. What action by the nurse is best?
- A. Assess the client's support system
- B. Assist in finding one change the client can control
- C. Determine what stressors the client faces in daily life
- D. Inquire about delegating some of the client's obligations
Correct Answer: B
Rationale: All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Assisting the client in choosing one change they feel optimistic about controlling is the most effective approach to build confidence and promote adherence.