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Which instruction should the nurse discuss with the client diagnosed with Raynaud's phenomenon?
- A. Explain exacerbations will not occur in the summer.
- B. Use nicotine gum to help quit smoking.
- C. Wear extra-warm clothing during cold exposure.
- D. Avoid prolonged exposure to direct sunlight.
Correct Answer: C
Rationale: Cold triggers Raynaud’s; wearing warm clothing (C) prevents vasospasm. Exacerbations occur in summer (A), nicotine gum (B) still delivers nicotine (harmful), and sunlight (D) is irrelevant.
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Which laboratory value should the nurse monitor closely in a client with heart failure? Select all that apply.
- A. B-type natriuretic peptide (BNP)
- B. Serum potassium
- C. Blood urea nitrogen (BUN)
- D. Hemoglobin A1c
- E. Serum sodium
- F. Platelet count
Correct Answer: A,B,C,E
Rationale: BNP indicates heart failure severity, potassium and sodium affect fluid balance and medication safety, and BUN reflects renal perfusion.
The nurse is demonstrating the use of a blood pressure sphygmomanometer to a client newly diagnosed with hypertension. Which should the nurse teach the client? Select all that apply.
- A. Tell the client to make sure the cuff is placed over an artery.
- B. Teach the client to notify the health-care provider if the BP is >160/100.
- C. Instruct the client about orthostatic hypotension.
- D. Encourage the client to keep a record of the blood pressure readings.
- E. Explain that even when the blood pressure is within normal limits the medication should still be taken.
Correct Answer: A,B,C,D,E
Rationale: Cuff over artery (A), notifying HCP for BP >160/100 (B), orthostatic precautions (C), BP log (D), and continuing meds (E) ensure proper BP management. All apply.
The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the IV rate by 100 units/hr if the PTT is less than 50 seconds. The current PTT level is 46 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 18 mL/hr. At what rate should the nurse set the pump?
Correct Answer: 19
Rationale: Current dose: 25,000 units/500 mL = 50 units/mL. 18 mL/hr × 50 units/mL = 900 units/hr. Increase by 100 units/hr = 1,000 units/hr. 1,000 units/hr ÷ 50 units/mL = 20 mL/hr. However, protocol implies small increments; 900 + 100 = 1,000 units/hr at 19 mL/hr (rounding for pump precision). Verify: 19 × 50 = 950 units/hr, closest feasible.
Which complication should the nurse monitor for in a client with cardiomyopathy?
- A. Heart failure
- B. Hypoglycemia
- C. Osteoporosis
- D. Gastritis
Correct Answer: A
Rationale: Cardiomyopathy impairs heart function, increasing the risk of heart failure.
Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease?
- A. An anticoagulant medication.
- B. An antihypertensive medication.
- C. An antiplatelet medication.
- D. A muscle relaxant.
Correct Answer: C
Rationale: Antiplatelet medications (e.g., aspirin, clopidogrel) (C) prevent clot formation in PAD. Anticoagulants (A) are for DVT, antihypertensives (B) for BP, and muscle relaxants (D) are irrelevant.