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Which health-care provider’s order should the nurse question in a client diagnosed with an expanding abdominal aortic aneurysm who is scheduled for surgery in the morning?
- A. Type and crossmatch for two (2) units of blood.
- B. Tap water enema until clear fecal return.
- C. Bedrest with bathroom privileges.
- D. Keep nothing by mouth (NPO) after midnight.
Correct Answer: B
Rationale: Enemas (B) risk increasing intra-abdominal pressure, dangerous in expanding AAA. Blood crossmatch (A), bedrest (C), and NPO (D) are appropriate pre-surgery.
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The client diagnosed with atherosclerosis asks the nurse, 'I have heard of atherosclerosis for many years but I never really knew what it meant. Am I going to die?' Which statement would be the nurse’s best response?
- A. This disease process will not kill you, so don’t worry.'
- B. The blood supply to your brain is being cut off.'
- C. It is what caused you to have your high blood pressure.'
- D. Atherosclerosis is a buildup of plaque in your arteries.'
Correct Answer: D
Rationale: Atherosclerosis is plaque buildup in arteries (D), a clear and accurate response. It’s not always fatal (A), doesn’t primarily affect brain (B), and isn’t the sole cause of hypertension (C).
The client with an arterial disorder reports cold feet. Which action should the nurse take first?
- A. Apply warm blankets to the feet.
- B. Check the pedal pulses bilaterally.
- C. Elevate the feet above heart level.
- D. Massage the feet to improve circulation.
Correct Answer: B
Rationale: Checking pedal pulses assesses arterial perfusion, which is critical in determining the cause of cold feet in arterial disorders.
The male client diagnosed with essential hypertension has been prescribed an alpha-adrenergic blocker. Which intervention should the nurse discuss with the client?
- A. Eat at least one (1) banana a day to help increase the potassium level.
- B. Explain that impotence is an expected side effect of the medication.
- C. Take the medication on an empty stomach to increase absorption.
- D. Change position slowly when going from a lying to sitting position.
Correct Answer: D
Rationale: Alpha blockers cause orthostatic hypotension; changing positions slowly (D) prevents falls. Bananas (A) are unrelated, impotence (B) is possible but not expected, and empty stomach (C) is not required.
Which teaching point should the nurse include for a client with endocarditis? Select all that apply.
- A. Report fever or chills immediately.
- B. Brush teeth gently to avoid gum bleeding.
- C. Avoid sharing toothbrushes.
- D. Take antibiotics for the full course.
- E. Monitor for signs of heart failure.
- F. Limit physical activity during treatment.
Correct Answer: A,B,C,D,E,F
Rationale: Reporting symptoms, gentle oral hygiene, avoiding shared items, completing antibiotics, monitoring heart failure, and limiting activity prevent complications.
The nurse is assessing a client with pericarditis. Which finding is most characteristic?
- A. Chest pain relieved by leaning forward
- B. Swelling in the ankles
- C. Fever above 103°F
- D. Bradycardia
Correct Answer: A
Rationale: Pericarditis causes chest pain that is typically relieved by leaning forward, reducing pressure on the inflamed pericardium.