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 D

Explanation

Choice D: This question is crucial as it addresses the client's adherence to their prescribed medication regimen for managing high blood pressure. Consistent medication use is essential for controlling blood pressure and reducing the risk of complications associated with hypertension. The elevated blood pressure reading suggests that the current medication regimen may not be effectively controlling the client's blood pressure. By assessing medication adherence, the nurse can determine if non-adherence is contributing to the high blood pressure reading or if adjustments to the medication regimen are required.

"Have you recently taken any antihistamines?": Asking about recent antihistamine use is not directly relevant to the client's high blood pressure reading of 210/106 mm Hg. Antihistamines are medications primarily used to relieve allergy symptoms and do not typically have a signiﬁcant impact on blood pressure levels.

"Have there been recent stressful events in your life?": While stress can contribute to temporary increases in blood pressure, asking about recent stressful events is not the most critical follow-up question in this situation. The client's blood pressure reading of 210/106 mm Hg indicates a severe elevation that requires immediate attention and management beyond stress reduction alone.

"Did you take any acetaminophen today?": Acetaminophen, also known as paracetamol, is a pain reliever and fever reducer. It does not typically have a signiﬁcant effect on blood pressure. Therefore, asking about acetaminophen use is not the most relevant follow-up question for the client's high blood pressure reading.

A. "My feet feel like I have pins and needles." B. "When I stand or sit too long, my feet swell." C. "My legs get a painful cramp when I walk over 30 minutes." D. "I get short of breath when I climb a lot of stairs.”

Correct Answer is C

Explanation

The client statement that supports the information of intermittent claudication is: "My legs get a painful cramp when I walk over 30 minutes.": Intermittent claudication is a symptom of peripheral artery disease (PAD) characterized by pain, cramping, or fatigue in the muscles of the lower extremities, typically the calves, thighs, or buttocks. This pain is usually triggered by physical activity, such as walking, and is relieved with rest. The pain is caused by inadequate blood flow and oxygen supply to the muscles due to narrowed or blocked arteries.

The other client statements do not specifically indicate intermittent claudication:

"My feet feel like I have pins and needles": This sensation of pins and needles is often associated with peripheral neuropathy, which is a condition involving nerve damage and does not directly relate to intermittent claudication.

"When I stand or sit too long, my feet swell": This statement suggests the possibility of venous insufficiency rather than intermittent claudication. Venous insufficiency involves impaired blood return from the legs to the heart and may result in swelling, aching, or heaviness in the legs.

"I get short of breath when I climb a lot of stairs": This symptom is more indicative of cardiovascular or respiratory issues, such as heart or lung disease, rather than intermittent claudication. It suggests that the client may experience exercise intolerance due to cardiopulmonary limitations.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with a history of high blood pressure. The client's blood pressure is 210/106 mm Hg during the assessment. What follow-up question should the nurse ask?

Correct Answer is D

Explanation

A nurse is assessing a client with intermittent claudication. What client statement supports this information?

Correct Answer is C

Explanation

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