NCLEX Challenge 5

NU 301 NCLEX Challenge 5 1. A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching? “I may eat 10 ounces of lean protein each day.” 2. A nurse is providing teaching to a client who has hypertension and a new prescription for captopril. Which of the following instructions should the nurse provide? Do not use salt substitutes while taking this medication. 3. A nurse is reviewing discharge instructions with a client who has Raynaud’s disease. Which of the following client statements indicates an understanding of the teaching? “I am going to take a stress management class.” 4. A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? Check the client’s vital signs. 5. A nurse is assessing a client who is taking lisinopril to treat hypertension. Which of the following findings is a priority to report? Swelling of the tongue. 6. A nurse is caring for a client who has deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? 24 mL/hr 7. A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect? Edema. 8. A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching? Adjust the thermostat so that the environment is warm. 9. A nurse is caring for a male client who has peripheral vascular disease (PVD), is taking dietary supplements, and has a new prescription for warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? (Select all that apply.) Saw palmetto Glucosamine Gingko biloba 10. A nurse is caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions? Asthma. 11. A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include? “Use elastic stockings.” 12. A nurse is caring for a client who has hypertension and is afraid to take his blood pressure medication. Which of the following nursing statements is an example of the therapeutic communication response of reflection? “You seem upset about taking your blood pressure medication.” 13. A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide? Take the medication early in the day. 14. A nurse is assessing a client’s cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers? The left second intercostal space. 15. A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take? Measure from the heel to the popliteal space. 16. A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?