The nurse provides care for a client diagnosed with hypertension. The client states, "I
no longer have headaches, so my blood pressure must be normal now." Which is the
best response for the nurse to give?
A. "If you no longer have headaches, then your blood pressure is probably normal"
B. "High blood pressure is usually asymptomatic and symptoms do not reliably indicate
blood pressure levels"
C. "Since you have lost weight, your blood pressure is probably lower."
D. "It is good to avoid strenuous exercise to keep your blood pressure lower" - Answer
B. "High blood pressure is usually asymptomatic and symptoms do not reliably indicate
blood pressure levels"
The nurse monitors a client diagnosed with hypertensions. The client tells the nurse, "I
have hypertension, but I haven't been taking my medication. I never refilled any of
prescriptions." Based on this information, how does the Nurse intervene?
A. Assesses the client's understanding of the importance of follow-up care and adhering
to the medication regimen.
B. Instructs the client to go to the health care provider immediately for re-evaluation.
C. Instructs the client about a low sodium diet since the client is not taking the
medication.
D. Insists the client go to the emergency department for a full evaluation. - Answer A.
Assesses the client's understanding of the importance of follow-up care and adhering to
the medication regimen.
A client undergoes a cardiac catheterization. Following the procedure, the nurse
assesses the client and discovers the client is bleeding from the sheath insertion site.
Which action does the nurse take first?
A. Takes the client's vital signs
B. Notifies the health care provider
C. Applies pressure to the site
D. Reinforces the dressing over the site. - Answer C. Applies pressure to the site
,The nurse assesses the laboratory values of a client with a suspected cute myocardial
infarction. Which data does the nurse understand is the most important in determining
myocardial tissue damage?
A. Triglycerides and cholesterol levels.
B. Lactate dehydrogenase (LDH)
C. Creatine kinase, isoenzyme MB (CK-MB)
D. Creatine kinase, isoenzyme MM (CK-MM) - Answer C. Creatine kinase, isoenzyme MB
(CK-MB)
The nurse provides care for a client diagnosed with MI. Which client statement indicates
to the nurse an understanding of initial lifestyle changes required to the MI?
A. "I'll be glad when this is over so I can get back to my old life. I have a lot planned, and
don't want to miss out on anything."
B. "Now that I'll have a few months off of work, I'd better have my spouse sing us up for
that hiking trip we were planning"
C. "I'm too young for this to happen. I know this is a big mistake. Once the HCP figures
that out, I'm going to have a serious talk with them."
D. "I guess I won't be playing volleyball with the guys for a while. I need to complete my
cardiac rehabilitation program." - Answer D. "I guess I won't be playing volleyball with
the guys for a while. I need to complete my cardiac rehabilitation program."
The nurse expects which laboratory test results to be elevated for a client following an
acute MI?
A. Creatine kinase (CK), troponin, and myoglobin
B. Blood urea nitrogen (BUN), serum creatinine, and protein-bound iodine
C. Aspartate aminotransferase (AST), red blood cell count (RBC), and platelets
D. Lactic dehydrogenase (LDH), thyroxine, and endorphin levels - Answer A. Creatine
kinase (CK), troponin, and myoglobin
Which risk factor does the nurse most likely to contribute to an elevation of a client's
blood pressure?
A. A high-pressure job
B. Consumption of whole grains with each meal
C. One glass of red wine per day
D. Walking daily - Answer A. A high-pressure job
, The nurse provides care for a client with a pulmonary artery catheter in place. Which
step is essential when obtaining a pulmonary capillary wedge pressure (PCWP)
reading?
A. The client must lie flat
B. Deflate the balloon quickly
C. Pull back on the syringe quickly when deflating the balloon
D. Deflate the balloon as soon as the PCWP reading is obtained. - Answer D. Deflate the
balloon as soon as the PCWP reading is obtained.
The nurse understands which reason is the cause of primary (essential) hypertension?
A. A high-sodium level
B. Kidney disease
C. Obesity
D. Unknown - Answer D. Unknown
The nurse provides care for a client with acute chest pain. The client's skin is cool and
clammy, and blood pressure and heart rate are elevated. The client appears short of
breath as well as restless and anxious. Which action does the nurse take first?
A. Takes a 12-lead electrocardiogram (ECG)
B. Assesses the client's pain and administers analgesia to client, as prescribed
C. Administers anticoagulants as prescribed
D. Gives a brief orientation to the unit. - Answer B. Assesses the client's pain and
administers analgesia to client, as prescribed
The nurse instructs the client how to prevent a UTI. Which client statement requires
further investigation?
A. "I can go all day without emptying my bladder"
B. "I drink 2L of fluid every day"
C. "I do not use bubble bath"
D. "I drink cranberry juice every day" - Answer A. "I can go all day without emptying my
bladder"
The nurse is inserting an indwelling urinary catheter into a female client. The nurse
notes the catheter is inserted into the client's vagina. Which action does the nurse take
first?
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