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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.
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Which lifestyle modification should the nurse emphasize for a client newly diagnosed with hypertension?
- A. Increase dietary sodium intake.
- B. Limit exercise to once a week.
- C. Reduce alcohol consumption.
- D. Sleep 4 hours per night.
Correct Answer: C
Rationale: Reducing alcohol consumption helps lower blood pressure, as excessive alcohol can elevate it.
The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins?
- A. Wear low-heeled, comfortable shoes.
- B. Wear clean white cotton socks.
- C. Move the legs back and forth often.
- D. Wear graduated compression hose.
Correct Answer: D
Rationale: Compression hose (D) prevent venous pooling, reducing varicose vein risk. Low heels (A), socks (B), and leg movement (C) help but are less effective.
The client with heart failure is prescribed digoxin. Which finding should the nurse report immediately?
- A. Heart rate of 58 beats per minute
- B. Potassium level of 3.2 mEq/L
- C. Blood pressure of 130/85 mmHg
- D. Respiratory rate of 18 breaths per minute
Correct Answer: B
Rationale: Hypokalemia (low potassium) increases the risk of digoxin toxicity, requiring immediate reporting.
The unlicensed assistive personnel (UAP) is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse?
- A. Removing compression stockings before assisting the client to bed.
- B. Taking the client’s blood pressure manually after using the machine.
- C. Assisting the client by opening the milk carton on the lunch tray.
- D. Calculating the client’s shift intake and output with a pen and paper.
Correct Answer: A
Rationale: Removing compression stockings (A) at night is incorrect; they should be worn to reduce edema. Manual BP (B), opening cartons (C), and I/O Calculation(ans only)s (D) are appropriate.
The client prescribed rivaroxaban (Xarelto), an anticoagulant, is complaining of dark, tarry stool. Which should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Ask the client to provide a stool sample.
- C. Ask the client when the rivaroxaban was last taken.
- D. Assess the client for ecchymotic areas and bleeding.
Correct Answer: A
Rationale: Dark, tarry stool suggests GI bleeding; notifying HCP (A) is first for urgent evaluation. Stool sample (B), last dose (C), and bleeding assessment (D) follow.