100% Correct
,The nurse should recognize that bumetanide is a loop-diuretic and eliminates potassium
in the urine. This client's potassium level is below the normal reference range of 3.5 to
5.0 mEq/L. The nurse should assess the client for manifestations of hypokalemia, such
as abdominal pain, muscle weakness, urinary retention, lethargy, confusion, and heart
dysrhythmias and contact the provider with the findings.
A nurse is reinforcing teaching with a client who has hypertension and a new
prescription for verapamil. The nurse should instruct the client to avoid taking this
medication with which of the following?
A) Milk
B) Orange juice
C) Cranberry juice D) Grapefruit juice ANS:
D) Grapefruit juice RATIONALE:
The nurse should instruct the client to avoid taking verapamil with grapefruit juice.
Grapefruit juice can inhibit the metabolism of verapamil, a calcium channel blocker, and
cause an increase in verapamil blood level. This excess amount of medication can
cause severe hypotension and cardiotoxicity.
A nurse is reinforcing teaching with a client who has a family history of hypertension.
The nurse should inform the client that his blood pressure reading of 124/84 mm Hg
places him in which of the following categories?
A) Prehypertension
B) Within the expected reference range
C) Hypertension stage 1
D) Hypertension stage 2 ANS:
A) Prehypertension
RATIONALE:
A blood pressure reading of 124/84 mm Hg places this client in the prehypertension
category. This includes a systolic pressure of 120 to130 mm Hg and a diastolic pressure
of 80 to 89 mm Hg.
Within the expected reference range
The expected reference range for blood pressure is less than 120 mm Hg systolic and
less than 80 mm Hg diastolic.
Hypertension stage 1
,Stage 1 hypertension presents with a systolic pressure of 140 to159 mm Hg and a
diastolic pressure of 90 to 99 mm Hg.
Hypertension stage 2
Stage 2 hypertension presents with a systolic pressure of greater than 60 mm hg and a
diastolic pressure of greater than 100 mm Hg.
, A nurse is reinforcing teaching with a client about following a low-cholesterol diet after
coronary artery bypass grafting. Which of the following food choices reflects the client's
understanding of these dietary instructions?
A) Liver
B) Milk
C) BeANS D) Eggs ANS:
C) BeANS
RATIONALE:
BeANS do not contain animal products. Therefore, they do not contain cholesterol.
BeANS are a good source of protein for a client who follows a low-cholesterol diet.
Liver
Cholesterol is in all animal tissue. Therefore, a client who needs a low-cholesterol
diet should avoid organ meats. Milk
Cholesterol is in all animal tissue, including foods that come from animal
sources. Therefore, a client who needs a low-cholesterol diet should avoid milk
and dairy products. Eggs
Cholesterol is in all animal tissue, including foods that come from animal sources.
Therefore, a client who needs a low-cholesterol diet should avoid eggs.
A nurse is reviewing blood pressure classification with a client who has been diagnosed
with hypertension. Which of the following should the nurse include as an example of
stage 1 hypertension?
A) 108/60 mm Hg
B) 128/88 mm Hg
C) 154/96 mm Hg C) 164/104 mm Hg ANS:
C) 154/96 mm Hg
RATIONALE:
Stage 1 hypertension includes systolic BP 140 to159 mm Hg or diastolic BP 90 to 99
mm Hg. This is an appropriate example for the nurse to include.
A nurse is caring for a client who has heart failure and is taking furosemide. For which
of the following findings should the nurse withhold the medication?
A) Crackles in bases of lungs
B) Peripheral edema
C) Ascites