A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of headache and blurred vision and has a blood pressure (BP) of 192/108 mmHg. Which question should the nurse ask to follow up on these findings?

"Have you recently taken any antihistamines?"

"Did you take any acetaminophen (Tylenol) today?"

"Have there been recent stressful events in your life?

"Have you consistently taken your medications?"

Answer and Explanation

The Correct Answer is D

A. Antihistamines can raise blood pressure, but this is less likely to be the primary cause compared to medication non-adherence.

B. Acetaminophen is generally safe for use in hypertensive patients and is unlikely to contribute to the high blood pressure in this scenario.

C. Stress can contribute to elevated blood pressure, but non-adherence to medications is a more likely cause of the severe BP elevation in this case.

D. Poor medication adherence is a common cause of elevated blood pressure despite treatment. If the client has not been consistently taking their antihypertensive medications, this could explain the elevated BP and symptoms (headache, blurred vision).

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Correct Answer is D

Explanation

A. Cutting toenails straight across is an appropriate action for PAD clients because it prevents injury or infection, as clipping nails too short or rounding the edges can cause cuts or ingrown nails.

B. Wearing shoes and socks instead of open-toed shoes is recommended to protect the feet from injury, as individuals with PAD have decreased sensation in their feet, increasing the risk of unnoticed injury.

C. Inspecting the feet daily for cuts is a crucial step in PAD management to detect early signs of infection or injury, which can lead to complications such as gangrene or amputation.

D. Raising the legs above the heart level can worsen symptoms in PAD by further reducing arterial blood flow to the lower extremities, where circulation is already compromised. This technique is typically used in venous insufficiency, not PAD.

A. Mark the surgical site with an "X B. Ask the client about their last food and fluid intake C. Educate the client that they will need to keep their leg straight for 6 hours after the procedure. D. Ask the client about their prescribed, over the counter, and herbal medication use E. Begin prophylactic heparin therapy prior to the procedure

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

Explanation

A. Marking the surgical site with an "X" is not typically done for cardiac catheterization. Instead, the healthcare provider may mark the site if necessary, but this is usually done by the surgeon or interventional cardiologist.

B. Asking about food and fluid intake is crucial because the client will need to be NPO (nothing by mouth) for several hours before the procedure to reduce the risk of aspiration during sedation or anesthesia.

C. Educating the client about keeping their leg straight after the procedure is necessary, but this typically occurs after the procedure, not before. This helps prevent complications such as bleeding or clot formation at the insertion site.

D. Asking about prescribed, over-the-counter, and herbal medications is important because certain medications, especially anticoagulants and blood thinners, need to be stopped before the procedure to minimize the risk of bleeding during catheterization.

E. Prophylactic heparin therapy may be ordered by the provider, but it is not typically administered by the nurse before the procedure unless specifically ordered.

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Naxlex Comprehensive Predictor Exams

The home care nurse has given instructions to a client who was recently discharged from the hospital regarding the care of their extremities due to peripheral arterial disease. The nurse determines that there is a need for further teaching if the client makes which statement?

Correct Answer is D

Explanation

A nurse is admitting a client who reports chest pain. Exhibits The nurse is preparing the client for the cardiac catheterization (coronary angiography). Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

The nurse is evaluating a client with multiple cardiovascular risk factors. Which of the following assessment findings would be most indicative of chronic venous insufficiency?

A patient who has recently started taking simvastatin (Zocor) reports several symptoms to the nurse. Which assessment finding is most important to communicate to the health care provider?

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

The nurse is reviewing laboratory values for a client receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor?

The nurse has finished teaching a patient diagnosed with chronic stable angina about the use of sublingual nitroglycerin (Nitrostat). Which patient statement indicates that the teaching has been effective?