Exhibits
The nurse is reviewing the client's medical record.
Select the 2 findings the nurse should identify as placing the client at risk for cardiovascular disease.
Exercise
Diet
LDL level
BMI
HDL level
Correct Answer : C,D
Rationale for Correct Answers:
- LDL level: An LDL level of 145 mg/dL exceeds the recommended limit (<130 mg/dL), increasing the client’s risk for atherosclerosis and coronary artery disease. Elevated LDL contributes to plaque buildup in arterial walls, narrowing the vessels and raising the likelihood of myocardial infarction and stroke.
- BMI: A BMI of 29.8 falls in the overweight range (25–29.9), nearing obesity. Excess body weight, particularly visceral fat, is associated with hypertension, insulin resistance, and dyslipidemia, all of which are significant risk factors for cardiovascular disease.
Rationale for Incorrect Answers:
- Exercise: The client walks 30 minutes 5 days a week, meeting the American Heart Association’s guidelines for physical activity. Regular aerobic exercise reduces blood pressure, improves lipid profiles, and strengthens cardiac function.
- Diet: The client reports following a Mediterranean diet, which is associated with lower cardiovascular risk due to its emphasis on fruits, vegetables, whole grains, lean protein, and healthy fats. Although wine consumption is noted, moderation aligns with Mediterranean patterns.
- HDL level: The client’s HDL is 58 mg/dL, which is above the desired threshold (>55 mg/dL). Higher HDL levels offer cardioprotective effects by helping remove cholesterol from the bloodstream and reducing the risk of plaque buildup.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Weighing clients is within the scope of an assistive personnel’s role, provided they have been properly trained in using facility equipment and understand the procedure. The nurse retains responsibility for ensuring the accuracy of the data and interpreting it.
B. This response focuses on the nurse’s ability rather than appropriate delegation. Delegating tasks helps manage time and resources effectively when delegation is safe and appropriate.
C. Weighing clients does not require nursing judgment; it is a routine, stable task that is appropriate for delegation under the right conditions.
D. Weights obtained on new clients may be needed before a full nursing assessment, but initial assessments must be performed by a nurse, not delegated to APs.
Correct Answer is C
Explanation
A. “Avoid high-fiber foods while taking this medication.”: Fentanyl can cause constipation, so a diet high in fiber is actually recommended to promote bowel regularity. Avoiding fiber would worsen one of the drug’s common side effects.
B. “Remove the patch for 8 hours every day to reduce the risk of tolerance.": Fentanyl patches are designed for continuous, 72-hour use. Removing the patch disrupts pain control and may lead to withdrawal symptoms or inadequate analgesia.
C. “Avoid hot tubs while wearing the patch.”: Heat exposure, including hot tubs or heating pads, can increase fentanyl absorption, potentially leading to overdose. Clients should be advised to avoid external heat sources near the patch.
D. “Apply the patch to your forearm.”: The patch should be applied to a flat, non-irritated area of the upper torso or upper arm. The forearm is not typically recommended due to its mobility and potential for detachment or reduced absorption.
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