Nokea
A client with a history of coronary artery disease is admitted with chest pain. Which of these findings would be most concerning to the nurse?
- A. Blood pressure of 130/80 mm Hg
- B. Respiratory rate of 20 breaths per minute
- C. Heart rate of 72 beats per minute
- D. Temperature of 98.6 degrees Fahrenheit
Correct Answer: B
Rationale: The correct answer is B. A respiratory rate of 20 breaths per minute may indicate respiratory distress in a client with chest pain. In a client with a history of coronary artery disease presenting with chest pain, signs of respiratory distress can be an alarming finding. Blood pressure within the normal range (130/80 mm Hg), heart rate of 72 beats per minute, and a temperature of 98.6 degrees Fahrenheit are generally considered within normal limits and may not be as concerning in this context.
You may also like to solve these questions
The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?
- A. It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat, and nose), skin, and lymph nodes.
- B. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain.
- C. Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
- D. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks.
Correct Answer: C
Rationale: The correct answer is C. Kawasaki disease occurs most often in boys and children younger than age 5, but there is no specific predisposition to children of Hispanic descent. Choice A is accurate, as Kawasaki disease does affect mucous membranes, skin, and lymph nodes. Choice B is correct, as peeling of the skin on the hands and feet with joint and abdominal pain are findings in the second phase of the disease. Choice D is accurate since initially, there is a sudden high fever that lasts 1 to 2 weeks.
A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values?
- A. Bleeding time
- B. Platelet count
- C. Activated PTT
- D. Clotting time
Correct Answer: C
Rationale: Activated PTT is the correct lab value to monitor for clients on heparin therapy. Activated PTT (partial thromboplastin time) helps assess the effectiveness of heparin therapy by measuring the time it takes for blood to clot. Monitoring activated PTT ensures that the client is within the therapeutic range of heparin to prevent both clotting and bleeding complications. Bleeding time (Choice A) and platelet count (Choice B) are not specific indicators of heparin therapy effectiveness. Clotting time (Choice D) is not as sensitive as activated PTT in monitoring heparin therapy.
A client who has received treatment for kidney stones should be reminded to increase intake of which of the following?
- A. Tea
- B. Sodium
- C. Water
- D. Protein
Correct Answer: C
Rationale: The correct answer is C: Water. Increasing water intake helps prevent the formation of new kidney stones by diluting the urine. Tea (Choice A) contains oxalates, which can contribute to kidney stone formation. Sodium (Choice B) should be limited to prevent the risk of certain types of kidney stones. Protein (Choice D) intake should be moderate as excessive protein consumption may increase the risk of kidney stones. Therefore, advising the client to increase water intake is the most appropriate recommendation to prevent the recurrence of kidney stones.
A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?
- A. Notify the healthcare provider
- B. Readjust the traction
- C. Administer the ordered PRN medication
- D. Reassess the foot in fifteen minutes
Correct Answer: A
Rationale: In this situation, a pale foot with the absence of a pulse indicates compromised circulation, which is a critical emergency. The nurse should immediately notify the healthcare provider to address the circulation issue promptly. Reading the question and understanding the urgency is vital. Readjusting the traction, administering PRN medication, or waiting to reassess the foot in fifteen minutes are not appropriate actions when a child is experiencing compromised circulation.
The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place the client in the wheelchair for four hours each day
- B. Pad the bony prominences
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Repositioning every two hours is the most effective measure in preventing skin breakdown for a client with a CVA. This practice helps to relieve pressure on the skin, reducing the risk of pressure ulcers. Placing the client in a wheelchair for extended periods (Choice A) can increase pressure on specific areas, leading to skin breakdown. Padding bony prominences (Choice B) can provide some protection but may not address the root cause of pressure ulcers. Massaging reddened bony prominences (Choice D) can potentially worsen the condition by causing further damage to already compromised skin.