The nurse is caring for a client scheduled for a cardiac stress test at 1100. When the nurse enters the client's room at 0800, the client requests toast or at least some coffee. What is the best response?

Explain that no food or drink is allowed for 4 hours before the stress test.

Ask the client's visitor to bring some coffee from the cafeteria for the client.

Make up a small breakfast tray from what is available on the unit.

Offer hot tea or coffee only.

Answer and Explanation

The Correct Answer is A

The best response by the nurse would be to explain that no food or drink is allowed for 4 hours before the stress test.

The reason for this restriction is that consuming food or drink can affect the accuracy of the cardiac stress test results. Eating or drinking can increase heart rate and blood pressure, potentially altering the test's interpretation. It is important for the client to have an empty stomach to ensure accurate test results.

Let's review the other options and explain why they are not the best responses:

Asking the client's visitor to bring some coffee from the cafeteria for the client: This option goes against the restriction of no food or drink before the stress test. It is important to adhere to the guidelines provided to ensure accurate test results.

Making up a small breakfast tray from what is available on the unit: Similarly, providing breakfast to the client goes against the restriction of no food before the stress test. The client should have an empty stomach for the test.

Offering hot tea or coffee only: While hot tea or coffee might be tempting for the client, it still violates the requirement of no food or drink before the stress test. The client should only be allowed to consume water during the fasting period.

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Correct Answer is C

Explanation

Maintaining a 2 gram-sodium (salt) diet is an important aspect of managing hypertension. High sodium intake can contribute to elevated blood pressure. Therefore, reducing sodium intake is recommended to help control blood pressure levels. The nurse should provide guidance on reading food labels, avoiding high-sodium processed foods, and incorporating a diet rich in fruits, vegetables, and whole grains.

The other options listed are not appropriate or beneficial for managing hypertension:

Maintaining a low-potassium diet: Potassium is an essential mineral that helps regulate blood pressure. While specific potassium restrictions may be necessary for some individuals with certain medical conditions, most people with hypertension do not need to limit their potassium intake. In fact, a balanced diet with adequate potassium is generally recommended.

Skipping a medication dose if dizziness occurs: It is not advisable to skip medication doses without consulting a healthcare provider. Hypertension medications are prescribed to help control blood pressure, and missing doses can lead to uncontrolled hypertension and potential complications. If the client experiences dizziness or other side effects from the medication, they should consult their healthcare provider for appropriate management.

Drinking three glasses of wine a day: Excessive alcohol consumption can contribute to elevated blood pressure. The recommended alcohol intake for individuals with hypertension is moderate or limited to moderate levels, which typically means no more than one drink per day for women and two drinks per day for men. Drinking excessive amounts of wine or any alcoholic beverage can negatively affect blood pressure control.

A. Document the information as a normal ﬁnding B. Prepare the client for an arterial bypass C. Educate the client about the use of compression stocking D. Anticipate a prescription for clopidogrel and simvastatin

Correct Answer is D

Explanation

An ABI of 0.89 indicates a reduced blood ﬂow to the lower extremities, which is suggestive of peripheral arterial disease (PAD). In PAD, there is narrowing or blockage of the arteries that supply blood to the legs and feet. Medications like clopidogrel and simvastatin are commonly prescribed for individuals with PAD to manage the condition and reduce the risk of complications.

Here's an explanation of why the other options are not the most appropriate interventions:

Document the information as a normal ﬁnding: An ABI of 0.89 is not considered a normal ﬁnding. An ABI value below 0.9 is generally indicative of PAD or reduced blood ﬂow to the lower extremities.

Prepare the client for an arterial bypass: An ABI value of 0.89 alone does not warrant immediate preparation for an arterial bypass. Arterial bypass surgery is typically considered for severe cases of PAD with signiﬁcant symptoms that signiﬁcantly impact the client's quality of life and other conservative treatments have not been successful.

Educate the client about the use of compression stockings: While compression stockings may be a part of the overall management of PAD, the ABI result alone does not indicate an immediate need for education about compression stockings. Other interventions, such as medication management, lifestyle modiﬁcations, and possibly revascularization procedures, may be more appropriate based on the severity of the PAD.

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The nurse is caring for a client scheduled for a cardiac stress test at 1100. When the nurse enters the client's room at 0800, the client requests toast or at least some coffee. What is the best response?

Nursing Test Bank

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Explanation

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Correct Answer is D

Explanation

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