Nokea
Which medication side effect should the nurse monitor for in a client taking an ACE inhibitor?
- A. Dry cough
- B. Weight gain
- C. Increased thirst
- D. Muscle cramps
Correct Answer: A
Rationale: ACE inhibitors commonly cause a dry cough due to increased bradykinin levels.
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Which instruction should the nurse provide to a client with a new implantable cardioverter-defibrillator (ICD)?
- A. Avoid strong magnetic fields.
- B. Carry heavy bags on the affected side.
- C. Resume contact sports in 2 weeks.
- D. Ignore any shocks you feel.
Correct Answer: A
Rationale: Strong magnetic fields can interfere with ICD function, so clients should avoid them.
Which medication would the nurse expect to administer to a client with an arterial disorder to improve blood flow?
- A. Warfarin (Coumadin)
- B. Clopidogrel (Plavix)
- C. Furosemide (Lasix)
- D. Metoprolol (Lopressor)
Correct Answer: B
Rationale: Clopidogrel is an antiplatelet medication that reduces the risk of clot formation, improving blood flow in arterial disorders.
The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse?
- A. The client takes a stool softener every day at dinnertime.
- B. The client is wearing a Medic Alert bracelet.
- C. The client takes vitamin E over-the-counter medication.
- D. The client has purchased a new recliner that will elevate the legs.
Correct Answer: C
Rationale: Vitamin E (C) increases bleeding risk with DVT anticoagulation, requiring intervention. Stool softeners (A), Medic Alert (B), and leg elevation (D) are appropriate.
The nurse is teaching the client diagnosed with deep vein thrombosis and prescribed warfarin. Which should the nurse teach the client? Select all that apply.
- A. Keep a constant amount of green, leafy vegetables in the diet.
- B. Instruct the client to have regular INR laboratory work done.
- C. Tell the client to go to the hospital immediately for any bleeding.
- D. Inform the client to notify the HCP if having dark, tarry stools.
- E. Encourage the client to avoid all green vegetables.
- F. Have the client take iron orally to prevent bleeding.
Correct Answer: A,B,D
Rationale: Constant green vegetable intake (A), regular INR (B), and reporting tarry stools (D) ensure safe warfarin use. Avoiding all greens (E) is unnecessary, and iron (C) doesn’t prevent bleeding. Immediate hospital for any bleeding (C) is excessive; minor bleeding requires HCP contact.
The client diagnosed with essential hypertension asks the nurse, 'Why do I have high blood pressure?' Which response by the nurse would be most appropriate?
- A. You probably have some type of kidney disease that causes the high BP.'
- B. More than likely you have had a diet high in salt, fat, and cholesterol.'
- C. There is no specific cause for hypertension, but there are many known risk factors.'
- D. You are concerned that you have high blood pressure. Let's sit down and talk.'
Correct Answer: C
Rationale: Essential hypertension has no single cause but multiple risk factors (e.g., genetics, lifestyle) (C). Kidney disease (A) or diet (B) may contribute but aren’t definitive, and concern (D) avoids the question.