Nokea
Which teaching point should the nurse include for a client with cardiomyopathy? Select all that apply.
- A. Monitor for signs of heart failure.
- B. Avoid alcohol consumption.
- C. Take medications as prescribed.
- D. Engage in high-intensity exercise.
- E. Report sudden weight gain.
- F. Limit fluid intake as advised.
Correct Answer: A,B,C,E,F
Rationale: Monitoring heart failure signs, avoiding alcohol, adhering to medications, reporting weight gain, and limiting fluids prevent complications.
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The client is at risk for a myocardial infarction due to decreased tissue perfusion as a result of atherosclerosis. Which instructions can the nurse provide the client to reduce the risk?
- A. Teach the client to control the blood pressure to less than 140/90.
- B. Instruct the client to exercise 30 minutes a day three (3) times a week.
- C. Demonstrate how to take the blood pressure using a battery-operated cuff.
- D. Inform the client to limit fat intake and which foods have a higher fat content.
Correct Answer: A,B,D
Rationale: Controlling BP <140/90 (A), exercising 30 min 3×/week (B), and limiting fat (D) reduce MI risk. BP cuff use (C) is monitoring, not prevention.
The nurse is assessing a client with hypertension. Which finding requires immediate action?
- A. Blood pressure of 160/100 mmHg
- B. Headache rated 4/10
- C. Blurred vision and confusion
- D. Pulse rate of 88 beats per minute
Correct Answer: C
Rationale: Blurred vision and confusion indicate a hypertensive crisis, which can lead to organ damage and requires immediate intervention.
Which instruction should the nurse include for a client with valvular heart disease?
- A. Avoid high-sodium foods.
- B. Increase caffeine intake.
- C. Limit fluid intake.
- D. Avoid regular exercise.
Correct Answer: A
Rationale: Avoiding high-sodium foods prevents fluid retention, reducing strain on the heart.
The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first?
- A. Check the PTT and PT/INR.
- B. Check with the HCP to see which drug should be discontinued.
- C. Administer both medications.
- D. Discontinue the heparin because the client is receiving Coumadin.
Correct Answer: A
Rationale: Check PTT (heparin) and PT/INR (warfarin) (A) to assess therapeutic levels before action. HCP check (B), administering (C), or discontinuing (D) depend on lab results (heparin often continues briefly with warfarin).
The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply.
- A. Place sequential compression devices on both legs.
- B. Instruct the client to stay in bed and not ambulate.
- C. Encourage fluids and a diet high in roughage.
- D. Monitor IV site every four (4) hours and prn.
- E. Assess Homans’ sign every 24 hours.
Correct Answer: A,C,D
Rationale: Compression devices (A), fluids/fiber (C), and IV monitoring (D) prevent DVT progression and complications. Bedrest (B) is not absolute (early ambulation is encouraged), and Homans’ sign (E) is unreliable.