Nokea
A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
- A. Shave the area before applying the patch
- B. Remove the old patch and clean the skin with alcohol
- C. Cover the patch with plastic wrap and tape it in place
- D. Avoid cutting the patch because it will alter the dose
Correct Answer: D
Rationale: Cutting a nitroglycerin patch can alter the dose by disrupting the drug delivery system, so clients should be instructed to avoid this.
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The client with a history of gout is prescribed allopurinol (Zyloprim). The nurse should instruct the client to:
- A. Limit fluid intake to prevent urinary complications.
- B. Take the medication with a full glass of water.
- C. Avoid foods high in calcium.
- D. Take the medication on an empty stomach.
Correct Answer: B
Rationale: Allopurinol reduces uric acid production, and taking it with a full glass of water promotes excretion of uric acid, preventing kidney stones. Fluid restriction is harmful, calcium is not restricted, and it can be taken with food.
A client with a history of heart failure is receiving Spironolactone (Aldactone). The nurse should teach the client to:
- A. Avoid potassium-rich foods
- B. Increase sodium intake
- C. Take the medication at bedtime
- D. Limit fluid intake
Correct Answer: A
Rationale: Spironolactone, a potassium-sparing diuretic, risks hyperkalemia, so potassium-rich foods should be avoided. Sodium restriction, daytime dosing, and fluid management are secondary.
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
- A. Denial
- B. Displacement
- C. Regression
- D. Projection
Correct Answer: C
Rationale: Regression involves reverting to an earlier developmental stage, such as dependency, in response to stress like a cancer diagnosis.
To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?
- A. Positive inotropic therapy
- B. Negative chronotropic therapy
- C. Increase in balance of myocardial O2 supply and demand
- D. Afterload reduction therapy
Correct Answer: A
Rationale: Inotropic therapy will increase contractility, which will increase myocardial O2 demand. Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand.
A 65-year-old client is admitted after a stroke. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
- A. Assessing the skin daily for breakdown
- B. Massaging any erythematous areas on the skin
- C. Changing incontinence pads as soon as they become soiled with urine or feces
- D. Performing range-of-motion exercises and turning and repositioning the client
Correct Answer: D
Rationale: Performing range-of-motion exercises and turning/repositioning enhances blood flow to tissues, reducing the risk of pressure ulcers by relieving pressure points. Assessing skin (A) is monitoring, not an intervention to improve perfusion. Massaging erythematous areas (B) can worsen tissue damage. Changing pads (C) prevents irritation but doesn’t directly improve perfusion.