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A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active?
- A. Presence of ascites
- B. Bilateral lung crackles
- C. Jugular vein distention
- D. Pedal edema bilaterally
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The healthcare provider is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The provider should place the highest priority on making sure that which is available at the bedside?
- A. Bedside commode
- B. Rolling shower chair
- C. Oxygen tubing and flowmeter
- D. Twelve-lead electrocardiogram (ECG) machine
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assisting a hospitalized client newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu, which meal should the nurse encourage the client to select?
- A. Sausage, pancakes, and toast
- B. Broccoli, buttered rice, and grilled chicken
- C. Hamburger, baked apples, and avocado salad
- D. Fresh strawberries, steamed vegetables, and baked fish
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client receives discharge teaching for a new prescription of lithium. Which instruction should be included?
- A. Take the medication with food.
- B. Increase your intake of sodium.
- C. Monitor for signs of hypercalcemia.
- D. Avoid consuming dairy products.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. What is the next appropriate nursing action?
- A. Administer another dose of nitroglycerin.
- B. Notify the healthcare provider immediately.
- C. Have the client lie down and stay calm.
- D. Give the client aspirin 325 mg to chew.
Correct Answer: A
Rationale: If chest pain persists after the first dose of nitroglycerin, it is appropriate to administer a second dose while continuing to monitor the client's response. Nitroglycerin is a vasodilator commonly used to relieve angina symptoms by dilating blood vessels and increasing blood flow to the heart. Reassessing the client's response and providing a second dose may be necessary to achieve adequate pain relief and improve blood flow to the heart.
A client with peripheral arterial disease complains of leg pain while walking. The nurse should reinforce which teaching point with the client?
- A. Wear compression stockings daily.
- B. Increase daily walking distance gradually.
- C. Elevate legs above heart level when resting.
- D. Use a heating pad to soothe leg muscles.
Correct Answer: B
Rationale: For clients with peripheral arterial disease experiencing leg pain while walking, gradually increasing daily walking distance is beneficial. This approach helps improve circulation, build tolerance, and reduce symptoms over time. Compression stockings can also be recommended for some clients to assist with circulation, but the priority teaching point in this scenario is to promote gradual increases in walking distance to enhance vascular health and symptom management.