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NCLEX Challenge 5 2021
- 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.”
- 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.
- 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.”
- 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.
- 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.
- 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
- A nurse is assessing a client who has chronic venous insufficiency. Which of the
following findings should the nurse expect?
Edema.
- 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.
- 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
- 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.
- 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.”
- 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.”
- 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.
- 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.
- 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.
- 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.
- 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.
- 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
- 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.
- 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.
- 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
- 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.”
- 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
- Where is the apical pulse on the picture?
- 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.
- 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.
- 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?
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