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 caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg is the most concerning finding as it indicates poor blood flow, potentially suggesting a serious circulatory problem that requires immediate attention. Diminished bowel sounds, loss of appetite, and tachypnea may be relevant but are not as indicative of a critical circulatory issue as a cold, pale lower leg.
For a client with chronic kidney disease having a hemoglobin level of 8.0 g/dL, which intervention should the nurse perform first?
- A. Administer erythropoietin as ordered
- B. Monitor the client's blood pressure
- C. Monitor the client's oxygen saturation level
- D. Assess the client for signs of fatigue
Correct Answer: A
Rationale: Administering erythropoietin is the priority intervention for a client with chronic kidney disease and a low hemoglobin level. Erythropoietin stimulates red blood cell production, helping to manage anemia in these clients. Monitoring blood pressure, oxygen saturation level, and assessing for signs of fatigue are important aspects of care but addressing the anemia by administering erythropoietin takes precedence to improve oxygen-carrying capacity and overall well-being.
A nurse is providing care to a 63-year-old client with pneumonia. Which intervention promotes the client's comfort?
- A. Increase oral fluid intake
- B. Encourage visits from family and friends
- C. Keep conversations short
- D. Monitor vital signs frequently
Correct Answer: C
Rationale: Keeping conversations short is the most appropriate intervention to promote comfort for a client with pneumonia. Pneumonia can be physically exhausting, and limiting the length of conversations helps conserve the client's energy. Encouraging visits from family and friends (Choice B) may be emotionally supportive but might not directly promote comfort in the context of conserving energy during recovery. Increasing oral fluid intake (Choice A) is important for hydration but may not directly address the client's comfort. Monitoring vital signs frequently (Choice D) is essential for assessing the client's condition but does not directly promote comfort.
The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?
- A. I use a sliding scale to adjust regular insulin to my sugar level.
- B. Since my eyesight is so bad, I ask the nurse to fill several syringes.
- C. I keep my regular insulin bottle in the refrigerator.
- D. I always make sure to shake the NPH bottle hard to mix it well.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?
- A. Pallor
- B. Increased temperature
- C. Dyspnea
- D. Involuntary muscle spasms
Correct Answer: C
Rationale: Dyspnea indicates a potential complication such as pneumothorax or incorrect catheter placement, requiring immediate attention. Pallor may indicate anemia but is not as urgent as dyspnea in this context. Increased temperature could be a sign of infection but is not as critical as respiratory distress. Involuntary muscle spasms are not directly related to central venous catheter placement and are of lower priority compared to respiratory issues.