Nokea
Which finding in a client with mitral stenosis requires immediate action?
- A. Heart rate of 100 beats per minute
- B. New onset of atrial fibrillation
- C. Blood pressure of 140/90 mmHg
- D. Mild fatigue
Correct Answer: B
Rationale: New-onset atrial fibrillation increases the risk of thromboembolism in mitral stenosis, requiring immediate intervention.
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The nurse is teaching the client diagnosed with arterial occlusive disease. Which interventions should the nurse include in the teaching? Select all that apply.
- A. Wash legs and feet daily in warm water.
- B. Apply moisturizing cream to feet.
- C. Buy shoes in the morning hours only.
- D. Do not wear any type of knee stocking.
- E. Wear clean white cotton socks.
Correct Answer: A,B,D,E
Rationale: Washing feet (A), moisturizing (B), avoiding knee stockings (D), and cotton socks (E) prevent skin breakdown and promote circulation in PAD. Morning shoe buying (C) is incorrect; shoes should be bought in the afternoon when feet are larger.
The client diagnosed with acute deep vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The healthcare provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take?
- A. Discontinue the heparin drip prior to initiating the Coumadin.
- B. Check the client's INR prior to beginning Coumadin.
- C. Clarify the order with the health-care provider as soon as possible.
- D. Administer the Coumadin along with the heparin drip as ordered.
Correct Answer: D
Rationale: Heparin and warfarin are often overlapped for 3–5 days in acute DVT until warfarin’s INR is therapeutic (D). Discontinuing heparin (A) is premature, INR (B) is checked later, and clarification (C) is unnecessary.
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.
The client with a mechanical heart valve reports a fever. What should the nurse do first?
- A. Administer acetaminophen.
- B. Notify the healthcare provider.
- C. Check the client's temperature again in 4 hours.
- D. Encourage fluid intake.
Correct Answer: B
Rationale: Fever may indicate endocarditis in a client with a mechanical valve, requiring immediate medical evaluation.
The nurse is assessing a client with dilated cardiomyopathy. Which finding is expected?
- A. Jugular vein distension
- B. Hypertension
- C. Dry skin
- D. Tachypnea
Correct Answer: A
Rationale: Dilated cardiomyopathy causes reduced cardiac output, leading to jugular vein distension from fluid backup.