Nokea
A client is admitted with a myocardial infarction and new onset atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as:
- A. Heart rate irregular with S3.
- B. Heart rate irregular with S4.
- C. Heart rate irregular with aortic regurgitation.
- D. Heart rate irregular with mitral stenosis.
Correct Answer: A
Rationale: An extra heart sound after S2 at the apex, constant through the respiratory cycle, is an S3, often associated with heart failure post-myocardial infarction. Atrial fibrillation causes an irregular heart rate.
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A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife does which of the following? Select all that apply.
- A. Administers long-acting or sustained-release oral pain formula (OxyContin) regularly around-the-clock.
- B. Administers immediate-release medication (oxycodone) for breakthrough pain.
- C. Avoids long-acting opioids due to her concern about addiction.
- D. Uses music for distraction as well as heat or cold in combination with medications.
- E. Substitutes acetaminophen (Tylenol) to avoid tolerance to the medications.
- F. Has her husband use a pain rating scale to measure the effectiveness at reaching his individual pain goal.
Correct Answer: A,B,D,F
Rationale: Effective pain management includes around-the-clock long-acting opioids (A), immediate-release opioids for breakthrough pain (B), non-pharmacologic methods like music or heat/cold (D), and using a pain scale to assess effectiveness (F). Avoiding long-acting opioids (C) or substituting acetaminophen (E) is not appropriate for severe cancer pain.
Which of the following will the nurse observe in the ictal phase of a generalized tonic-clonic seizure?
- A. Linking in one extremity that spreads gradually to adjacent areas.
- B. Vacant staring and abruptly ceasing all activity.
- C. Facial grimaces, patting motions, and lip smacking.
- D. Loss of consciousness, body stiffening, and violent muscle contractions.
Correct Answer: D
Rationale: The ictal phase of a generalized tonic-clonic seizure is characterized by loss of consciousness, body stiffening (tonic phase), and violent muscle contractions (clonic phase). The other options describe focal or absence seizures.
The client is a survivor of non-Hodgkin's lymphoma. Which of the following statements indicates the client needs additional information?
- A. Regular screening is very important for me.'
- B. The survivor rate is directly proportional to the incidence of second malignancy.'
- C. The survivor rate is indirectly proportional to the incidence of second malignancy.'
- D. It is important for survivors to know the stage of the disease and their current treatment plan.'
Correct Answer: B
Rationale: The survival rate for non-Hodgkin's lymphoma is inversely proportional to the incidence of second malignancies, as secondary cancers reduce survival. The statement that it is directly proportional indicates a misunderstanding. Regular screening, knowing disease stage, and treatment plans are correct.
Which statement by a client with a new ileal conduit indicates a need for further teaching?
- A. I will empty the pouch when it is one-third full.
- B. I can use vinegar to clean my appliance.
- C. I should drink 2,000 mL of fluid daily.
- D. I will wear tight clothing to hide the pouch.
Correct Answer: D
Rationale: Tight clothing can irritate the stoma and impair appliance function, indicating a misunderstanding of proper care.
A client is admitted to the unit with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency room, and I.V. heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve:
- A. Administering aspirin as ordered
- B. Encouraging green leafy vegetables in the diet
- C. Monitoring the client's prothrombin time (PT)
- D. Monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (INR)
Correct Answer: D
Rationale: Heparin therapy for DVT requires monitoring aPTT to ensure therapeutic anticoagulation (1.5–2.5 times baseline). INR is less relevant for heparin but may be monitored if transitioning to warfarin. Aspirin is not typically used, and green leafy vegetables (high in vitamin K) may affect warfarin, not heparin.