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Which instruction should the nurse include for a client with heart failure to monitor fluid status?
- A. Check blood pressure twice daily.
- B. Weigh yourself every morning.
- C. Record urine color daily.
- D. Measure abdominal girth weekly.
Correct Answer: B
Rationale: Daily weight monitoring detects fluid retention early, as 1 liter of fluid equals approximately 2.2 pounds.
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The client presents to the outpatient clinic complaining of calf pain. The client reports returning from an airplane trip the previous day. Which should the nurse assess first?
- A. The nurse should auscultate the lung fields and heart sounds.
- B. The nurse should determine the length of the airplane trip.
- C. The nurse should determine if the client has had chest pain.
- D. The nurse should measure the calf and palpate the calf for warmth.
Correct Answer: C
Rationale: Calf pain post-flight suggests DVT; assessing for chest pain (C) rules out pulmonary embolism, a priority. Lung/heart sounds (A), trip length (B), and calf exam (D) follow.
As the nurse provides discharge instructions to the client with varicose veins, which activity should the nurse suggest the client avoid?
- A. Walking in athletic shoes.
- B. Jogging a mile a day.
- C. Sitting with crossed knees.
- D. Wearing wool socks.
Correct Answer: C
Rationale: Sitting with crossed knees can compress veins, worsening venous stasis in clients with varicose veins.
When offered the pain medication, the client says to the nurse, 'If that's Motrin, I don't want it. It makes me sick to my stomach.' What is the most appropriate nursing action at this time?
- A. Tell the client that the drug is ibuprofen.
- B. Explain that the prescribed medication must be taken.
- C. Advise the client to take the drug with plenty of water.
- D. Report the information to the charge nurse.
Correct Answer: D
Rationale: Reporting the client's adverse reaction to the charge nurse ensures proper communication and potential adjustment of the medication plan.
The 66-year-old male client has his blood pressure (BP) checked at a health fair. The BP is 168/98. Which action should the nurse implement first?
- A. Recommend that the client have his blood pressure checked in one (1) month.
- B. Instruct the client to see his health-care provider as soon as possible.
- C. Discuss the importance of eating a low-salt, low-fat, low-cholesterol diet.
- D. Explain that this BP is within the normal range for an elderly person.
Correct Answer: B
Rationale: BP 168/98 indicates stage 2 hypertension, requiring prompt HCP evaluation (B). Waiting a month (A) delays care, diet discussion (C) is secondary, and normal range (D) is incorrect (normal is <120/80).
The client with restrictive cardiomyopathy asks why they feel short of breath. What is the best response?
- A. Your heart cannot fill properly.
- B. Your lungs are inflamed.
- C. Your blood pressure is too low.
- D. Your heart rate is too fast.
Correct Answer: A
Rationale: Restrictive cardiomyopathy impairs ventricular filling, reducing cardiac output and causing shortness of breath.