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Which finding in a client with cardiomyopathy indicates a need for immediate action?
- A. Blood pressure of 130/85 mmHg
- B. New irregular heart rhythm
- C. Mild leg swelling
- D. Fatigue after activity
Correct Answer: B
Rationale: A new irregular heart rhythm may indicate a life-threatening arrhythmia, requiring immediate intervention.
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The nurse is monitoring a client with atrial fibrillation. Which finding is most concerning?
- A. Heart rate of 110 beats per minute
- B. Blood pressure of 140/90 mmHg
- C. Dizziness and shortness of breath
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Dizziness and shortness of breath suggest hemodynamic instability, which is concerning in atrial fibrillation.
Which diagnostic test would the nurse expect to be ordered for a client suspected of having an arterial disorder?
- A. Ankle-brachial index (ABI)
- B. Venous duplex ultrasound
- C. D-dimer blood test
- D. Complete blood count (CBC)
Correct Answer: A
Rationale: The ankle-brachial index (ABI) is a non-invasive test that compares blood pressure in the ankle and arm to diagnose peripheral artery disease.
The nurse is teaching the Dietary Approaches to Stop Hypertension (DASH) diet to a client diagnosed with essential hypertension. Which statement indicates that the client understands teaching concerning the DASH diet?
- A. I should eat at least four (4) to five (5) servings of vegetables a day.'
- B. I should eat meat that has a lot of white streaks in it.'
- C. I should drink no more than two (2) glasses of whole milk a day.'
- D. I should decrease my grain intake to no more than twice a week.'
Correct Answer: A
Rationale: The DASH diet emphasizes 4–5 servings of vegetables daily (A) to lower BP. Marbled meat (B) is high-fat, whole milk (C) is limited, and grains (D) are encouraged (6–8 servings daily).
The client on the telemetry unit diagnosed with a thromboembolism is complaining of chest pain and anxiety. Which action should the nurse implement first?
- A. Stay with the client and call the Rapid Response Team (RRT).
- B. Assess the client’s vital signs.
- C. Have the unlicensed assistive personnel (UAP) stay with the client.
- D. Check the client’s telemetry reading.
Correct Answer: A
Rationale: Chest pain/anxiety in thromboembolism suggests pulmonary embolism; calling RRT (A) ensures rapid intervention. Vitals (B), UAP (C), and telemetry (D) follow.
The nurse is teaching the client about risk factors for arterial disorders. Which modifiable risk factor should the nurse emphasize?
- A. Age over 60 years
- B. Family history of heart disease
- C. Smoking cigarettes
- D. Male gender
Correct Answer: C
Rationale: Smoking is a modifiable risk factor that significantly contributes to arterial disorders by causing vasoconstriction and endothelial damage.