A client is experiencing angina at rest. Which statement indicates a good understanding of the care required?
- A. I will notify the nurse if my chest pain is not relieved in 30 minutes.
- B. I will use nitroglycerin as needed, every 5 minutes, up to 3 doses.
- C. I will avoid physical activity until the pain subsides completely.
- D. I will take nitroglycerin 30 minutes before any physical activity.
Correct Answer: B
Rationale: The correct answer is B. Using nitroglycerin as needed, every 5 minutes, up to 3 doses, is the appropriate management for angina at rest. This helps dilate blood vessels, improving blood flow to the heart. Choice A is incorrect because chest pain that persists at rest should be addressed immediately, not waiting for 30 minutes. Choice C is incorrect as avoiding physical activity is not a recommended approach during an angina episode. Choice D is incorrect because nitroglycerin should be used during chest pain episodes, not as a preventive measure before physical activity.
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A client who recently had a hip replacement has a strong odor from the urine and bloody drainage on the surgical dressing. What should the nurse do first?
- A. Obtain a urine sample from the bedpan.
- B. Insert an indwelling urinary catheter.
- C. Measure the client's oral temperature.
- D. Remove dressing and assess surgical site.
Correct Answer: C
Rationale: The correct answer is to measure the client's oral temperature. In this scenario, the strong odor from urine and bloody drainage on the surgical dressing are concerning signs that suggest a possible infection. Fever is a common sign of infection, so measuring the client's temperature will help confirm if an infection is present. Obtaining a urine sample, inserting an indwelling urinary catheter, or removing the dressing and assessing the surgical site are not the first priority actions when infection is suspected. These actions may be necessary later but assessing the client's temperature is the initial step to evaluate for infection.
A pregnant client complains of heartburn. What instruction should the nurse provide?
- A. Eat spicy food to help digestion.
- B. Eat small meals throughout the day to avoid a full stomach.
- C. Drink carbonated beverages to ease digestion.
- D. Avoid drinking fluids after meals.
Correct Answer: B
Rationale: The correct instruction for a pregnant client experiencing heartburn is to eat small meals throughout the day to avoid a full stomach. This helps prevent the stomach from becoming overly full, reducing the likelihood of heartburn during pregnancy. Choices A, C, and D are incorrect. Eating spicy food can exacerbate heartburn, carbonated beverages may trigger heartburn due to gas, and avoiding fluids after meals does not directly address the issue of heartburn.
The nurse is providing discharge instructions to a client with chronic venous insufficiency. Which recommendation should the nurse include to help prevent complications?
- A. Use a heating pad on the legs
- B. Wear compression stockings
- C. Massage the legs daily
- D. Elevate legs for 10 minutes every hour
Correct Answer: B
Rationale: The correct recommendation for a client with chronic venous insufficiency to prevent complications is to wear compression stockings. Compression stockings help improve venous circulation and prevent the worsening of symptoms. While elevating the legs is also beneficial, the priority intervention in preventing complications is wearing compression stockings. Using a heating pad on the legs can actually worsen the condition by dilating blood vessels, and massaging the legs daily can potentially damage fragile skin in clients with chronic venous insufficiency.
A client with tuberculosis is prescribed rifampin. What side effect should the nurse inform the client about?
- A. Report orange-colored urine as a sign of kidney dysfunction.
- B. Expect red-orange discoloration of urine as a harmless side effect.
- C. Monitor for signs of liver toxicity.
- D. Call the healthcare provider if vision changes occur.
Correct Answer: B
Rationale: The correct answer is B. Rifampin can cause red-orange discoloration of bodily fluids, including urine, saliva, and tears. This is a harmless side effect, but clients should be informed beforehand to prevent alarm. Choice A is incorrect as orange-colored urine is not a sign of kidney dysfunction related to rifampin. Choice C is incorrect because rifampin is more commonly associated with liver toxicity rather than kidney dysfunction. Choice D is incorrect as vision changes are not a typical side effect of rifampin.
An older client with a long history of coronary artery disease, HTN, and HF arrives in the ED in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expect in the client with acute HF?
- A. Decreased heart rate
- B. Improved blood pressure
- C. Increased urine output
- D. Reduced preload
Correct Answer: D
Rationale: The correct answer is D: Reduced preload. Furosemide is a diuretic that reduces fluid overload in heart failure, which lowers the preload (the volume of blood in the ventricles before contraction). By reducing this volume, furosemide improves symptoms of heart failure. While furosemide may lead to increased urine output and lower blood pressure, these effects are secondary to the reduction in preload. Decreased heart rate is not a direct effect of furosemide in heart failure.