Nokea
Which medication should the nurse expect for a client with valvular heart disease and atrial fibrillation?
- A. Warfarin (Coumadin)
- B. Aspirin
- C. Metoprolol (Lopressor)
- D. Furosemide (Lasix)
Correct Answer: A
Rationale: Warfarin prevents thromboembolism in clients with valvular heart disease and atrial fibrillation.
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The client with endocarditis is at risk for which complication?
- A. Embolism
- B. Hypoglycemia
- C. Osteoarthritis
- D. Pancreatitis
Correct Answer: A
Rationale: Endocarditis can cause vegetations on heart valves, which may break off and form emboli.
Which intervention should the nurse include in the plan of care for a client with an arterial ulcer?
- A. Apply a dry, sterile dressing daily.
- B. Elevate the affected leg above heart level.
- C. Encourage ambulation for 30 minutes daily.
- D. Keep the ulcer moist with a hydrogel dressing.
Correct Answer: D
Rationale: Arterial ulcers require a moist wound environment to promote healing, as dry dressings can adhere to the wound and impair tissue regeneration.
Which assessment data would warrant immediate intervention by the nurse?
- A. The client diagnosed with DVT who complains of pain on inspiration.
- B. The immobile client who has refused to turn for the last three (3) hours.
- C. The client who had an open cholecystectomy who refuses to breathe deeply.
- D. The client who has had an inguinal hernia repair who must void before discharge.
Correct Answer: A
Rationale: Pain on inspiration in DVT (A) suggests pulmonary embolism, requiring immediate action. Immobility (B), shallow breathing (C), and voiding (D) are less urgent.
The nurse is caring for a client diagnosed with deep vein thrombosis. Which information reported to the nurse by the unlicensed assistive personnel (UAP) requires immediate intervention?
- A. The UAP informed the nurse the client is complaining of chest pain.
- B. The UAP notified the nurse the client’s blood pressure is 100/66.
- C. The UAP reported the client is requesting to be able to take a shower.
- D. The UAP tells the nurse the client is asking for medication for a headache.
Correct Answer: A
Rationale: Chest pain in DVT (A) suggests pulmonary embolism, requiring immediate intervention. Hypotension (B), showering (C), and headache (D) are less urgent.
The client with hypertension asks why they need to limit stress. What is the best response?
- A. Stress causes fluid retention.
- B. Stress increases your heart rate and blood pressure.
- C. Stress reduces oxygen to your heart.
- D. Stress weakens your immune system.
Correct Answer: B
Rationale: Stress activates the sympathetic nervous system, increasing heart rate and blood pressure.