The nurse on the intermediate care unit received change-of-shift report on four clients with hypertension. Which patient should the nurse assess ﬁrst?

A client with a blood pressure of 190/92 mm Hg who reports chest pain

A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia

A client with a blood pressure of 178/90 mm Hg who has intermittent claudication

A client with a blood pressure of 172/98 mm Hg scheduled for a stress test

Answer and Explanation

The Correct Answer is A

The nurse should assess the client with a blood pressure of 190/92 mm Hg who reports chest pain ﬁrst. Chest pain can be a symptom of myocardial ischemia or a heart attack, which requires immediate attention. The combination of high blood pressure and chest pain is concerning and may indicate acute coronary syndrome. Prompt assessment and intervention are crucial to evaluate the cause of the chest pain and initiate appropriate treatment.

A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia: While sinus tachycardia may indicate increased heart rate, it does not necessarily require immediate assessment unless other concerning symptoms are present. However, the nurse should address the elevated blood pressure in a timely manner.

Intermittent claudication refers to leg pain or discomfort during physical activity due to reduced blood ﬂow. While it is important to assess and manage this symptom, it is not typically considered an urgent condition requiring immediate assessment compared to chest pain.

The client scheduled for a stress test may have elevated blood pressure, but if they are stable and not currently experiencing symptoms, they may not require immediate assessment compared to a client with chest pain.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

The information that the nurse should include in the discharge teaching for the client who is three days post-operative abdominal aortic aneurysm repair is as follows:

Notify the healthcare provider (HCP) of any redness or irritation of the incision: This is important because redness or irritation can be signs of infection or other complications at the surgical site. Prompt reporting allows for early intervention and management.

Do not lift anything more than 20 pounds: Following abdominal aortic aneurysm repair, it is crucial to avoid heavy lifting or straining as it can put excessive pressure on the surgical site and potentially lead to complications such as incisional hernia. Restricting lifting to no more than 20 pounds helps to protect the incision and promote proper healing.

Inform the client that there may be pain not relieved with pain medication: Pain management is an essential aspect of post-operative care. However, it is important for the client to understand that complete relief of pain may not always be achievable with pain medication alone. They should be aware that mild to moderate discomfort may persist during the healing process, but severe or worsening pain should be reported to the healthcare provider.

Stress the importance of having daily bowel movements: After abdominal surgery, it is common for bowel movements to be delayed due to factors such as anesthesia, reduced activity, and pain medication. However, it is crucial for the client to maintain regular bowel movements to prevent constipation and potential complications such as bowel obstruction. The nurse should provide guidance on strategies to promote regular bowel function, such as staying hydrated, eating a balanced diet rich in fiber, and using stool softeners or gentle laxatives as directed by the healthcare provider.

A. Instruct the client to drink 1 L of water before the test. B. Administer intravenous (IV) benzodiazepines and opioids. C. Inform the client that the client will remain on bed rest following the procedure D. Inform the client that an access line will be initiated in the femoral artery.

Correct Answer is D

Explanation

Transesophageal echocardiography is a diagnostic procedure that involves inserting a probe into the esophagus to obtain detailed images of the heart. In some cases, an access line may be initiated in the femoral artery to monitor blood pressure during the procedure and administer medications if needed. Informing the client about this aspect of the procedure helps ensure that they are aware of what to expect and can provide informed consent.

Let's go through the other options and explain why they are not the most appropriate actions:

Instruct the client to drink 1 L of water before the test: This action is not necessary for transesophageal echocardiography. Drinking water before the test is typically done for certain abdominal or pelvic ultrasound examinations to provide better visualization. However, for TEE, the probe is inserted into the esophagus, and drinking water is not required.

Administer intravenous (IV) benzodiazepines and opioids: The administration of intravenous benzodiazepines and opioids is not a routine part of preparing a client for TEE. The need for sedation or analgesia during the procedure would be determined based on the individual client's condition and level of discomfort.

Inform the client that the client will remain on bed rest following the procedure: While some post-procedure instructions may be given to the client, such as avoiding eating or drinking until the effects of sedation wear off, informing the client that they will remain on bed rest following the procedure is not a speciﬁc requirement for TEE. Post-procedure instructions can vary depending on the individual client's condition and the healthcare provider's recommendations.

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The nurse on the intermediate care unit received change-of-shift report on four clients with hypertension. Which patient should the nurse assess ﬁrst?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is discussing discharge teaching with the client who is three (3) days post-operative abdominal aortic aneurysm repair. Which information should the nurse include in the teaching?

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is preparing a client for scheduled transesophageal echocardiography. Which action should the nurse perform?

Correct Answer is D

Explanation

The nurse is providing discharge education to a client who recently have insertion of a pacemaker/ICD. Which statement by the client should require further follow up by the nurse?

The nurse is providing discharge teaching to a client with venous insufficiency about compression stockings. Which information is essential for the nurse in the teaching plan?

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The nurse is performing a 12-lead ECG on a male client with abundant chest hair. What is the most appropriate nursing intervention to improve adhesion of the ECG leads?

A client with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the client in anticipation of this diagnostic procedure?

The nurse is teaching a client with peripheral arterial disease. Which information should the nurse include in the teaching plan?

The nurse is teaching a client with atrial ﬂutter who is scheduled for a catheter ablation? What should the nurse include in the teaching plan?

The nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency. Which intervention is the most appropriate for this diagnosis?