Nokea
A client is being seen in the clinic to rule out (R/O) mitral valve stenosis. Which assessment data would be most significant?
- A. The client complains of shortness of breath when walking.
- B. The client has jugular vein distention and 3+ pedal edema.
- C. The client complains of chest pain after eating a large meal.
- D. The client's liver is enlarged and the abdomen is edematous.
Correct Answer: A
Rationale: Shortness of breath on exertion (A) is a hallmark of mitral valve stenosis due to impaired left atrial emptying. JVD/edema (B), postprandial pain (C), and liver/abdominal edema (D) suggest right-sided failure or other causes.
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The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement?
- A. Instruct the UAP to stop encouraging the leg movements.
- B. Report this behavior to the charge nurse as soon as possible.
- C. Praise the UAP for encouraging the client to move the legs.
- D. Take no action concerning the UAP's behavior.
Correct Answer: C
Rationale: Leg movements (C) prevent DVT in MI patients on bedrest, so praising the UAP is appropriate. Stopping (A), reporting (B), or ignoring (D) are incorrect.
The nurse is teaching an adult who has angina about taking nitroglycerin. The nurse tells him he will know the nitroglycerin is effective when:
- A. he experiences tingling under the tongue.
- B. his pulse rate increases.
- C. his pain subsides.
- D. his activity tolerance increases.
Correct Answer: C
Rationale: The effectiveness of nitroglycerin is indicated by the relief of anginal pain. Tingling, increased pulse rate, or improved activity tolerance are not direct indicators of its effectiveness.
An adult client who has peripheral vascular disease of the lower extremities was observed smoking in the waiting area. What is the most appropriate response for the nurse to make regarding the client's smoking?
- A. Smoking is not allowed for patients with blood diseases.'
- B. Smoking causes the blood vessels in your legs to constrict and reduces the blood supply.'
- C. Smoking increases your blood pressure and strains your heart.'
- D. Smoking causes your body to be under greater stress.'
Correct Answer: B
Rationale: Smoking causes vasoconstriction, worsening blood flow in peripheral vascular disease, which directly impacts the condition. Other responses are less specific to the client’s diagnosis.
The nurse is transcribing the doctor’s orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement?
- A. Discuss the order with the health-care provider.
- B. Take the client’s apical pulse rate before administering.
- C. Check the client’s potassium level before giving the medication.
- D. Determine if a digoxin level has been drawn.
Correct Answer: A
Rationale: Lanoxin (digoxin) 2.5 mg (A) exceeds the safe dose (0.125–0.25 mg daily), requiring HCP clarification. Pulse (B), potassium (C), and digoxin level (D) are routine but secondary to dose error.
An adult is admitted with venous thromboembolism. What treatment should the nurse expect during the acute stage?
- A. Application of an elastic stocking
- B. Ambulation three times a day
- C. Passive range of motion exercises to the legs
- D. Use of ice packs to control pain
Correct Answer: A
Rationale: Elastic stockings promote venous return and reduce swelling in the acute stage of venous thromboembolism. Ambulation, passive exercises, or ice packs may increase risk or be less effective.