University of South Alabama: NU 301 NCLEX Challenge 5 Questions and Answers,100% CORRECT

University of South Alabama: NU 301NCLEX Challenge 5 Questions and Answers 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? Breathlessness. 17. A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor? Cigarette smoking. 18. A nurse is preparing to administer heparin 2,000 units by IV bolus. Available is heparin injection 5,000 units/mL. How many mL should the nurse administer? 0.4 mL 19. A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? Frothy sputum. 20. A nurse is reviewing the medical record of a client who has hypertension and a new prescription for metoprolol. Which of the following findings should the nurse investigate further? A history of left-sided heart failure. 21. A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.) Hypercholesterolemia Hypertension Obesity Smoking 22. A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? “Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level.” 23. A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.) Oral contraceptive use Immobility 24. Where is the apical pulse on the picture? 25. A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? The client will walk for 30 minutes 5 days a week. 26. A nurse is caring for a client who is on warfarin therapy for atrial fibrillation. The client’s INR is 5.2. Which of the following medications should the nurse prepare to administer? Vitamin K. 27. A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis? Vertigo. 28. Where is the posterior tibial pulse? 29. A nurse is preparing to administer heparin to a client. Which of the following actions should the nurse plan to take? Inject the medication into the abdomen above the level of the iliac crest. 30. A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client? Peripherally inserted central catheter. 31. A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective? “I plan to slow down if I am tired the day after exercising.” 32. Where is the most distal pulse on affected side of left femoral cardiac angiography? 33. A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk? LDL 172 mg/dL 34. A nurse is preparing to insert an IV catheter for a client and has selected the insertion site. Place the following steps in the order in which the nurse should perform them. Apply a tourniquet or BP cuff Cleanse the site with an antiseptic swab Dilate the vein Insert the catheter Flush the catheter 35. A nurse is caring for a client who receives furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client due to this medication? Potassium. 36. A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply.) Hypotension Weak pulses Murmur 37. A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease? Intermittent claudication. 38. While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client’s care? Impaired tissue perfusion. 39. A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet? “I eat two eggs for breakfast each morning.” 40. 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? “Heparin does not dissolve clots. It stops new clots from forming.” 41. A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client’s comfort? Obtain a pair of slipper-socks for the client. 42. A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching? “Increasing my intake of foods containing trans-fatty acids can lower my risk.” 43. A nurse is providing discharge instructions to a client who developed DVT postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? Flexing her knees and feet frequently. 44. A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching? Exercise at least three times per week. 45. A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that apply.) Dyspnea Jugular vein distention Confusion 46. A nurse is assessing a client who is at risk for DVT. Which of the following findings is a manifestation of DVT? Groin tenderness. 47. A nurse is instructing a client who has a new diagnosis of Raynaud’s disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? “I will take my medications at the first sign of an attack.” 48. A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension? Obstructive sleep apnea (OSA). 49. A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin? Prothrombin time (PT). 50. A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? Dyspnea. 51. A nurse is assessing a client’s radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? Assess the apical pulse for a full minute.