Nokea
A client with coronary artery disease (CAD) is taking a low-dose aspirin daily. The nurse is reinforcing teaching with the client. The nurse should include that this medication has which of the following therapeutic effects?
- A. Analgesic
- B. Antiplatelet
- C. Anticoagulant
- D. Thrombolytic
Correct Answer: B
Rationale: The correct answer is B: Antiplatelet. Aspirin works by inhibiting platelet aggregation, making it an antiplatelet agent. This effect helps reduce the risk of blood clot formation in clients with CAD. Choice A, Analgesic, is incorrect because aspirin's primary action in this context is not pain relief. Choice C, Anticoagulant, is incorrect as aspirin does not directly inhibit coagulation factors. Choice D, Thrombolytic, is incorrect as aspirin does not actively break down clots but rather prevents their formation.
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A client with coronary artery disease (CAD) is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?
- A. Increase your intake of red meat
- B. Increase physical activity to 150 minutes per week
- C. Avoid foods high in fiber
- D. Increase sodium intake to 2,300 mg per day
Correct Answer: B
Rationale: The correct answer is B: 'Increase physical activity to 150 minutes per week.' Increasing physical activity is essential for clients with CAD as it helps reduce the risk of cardiovascular events. Choice A is incorrect as red meat is high in saturated fats, which can be detrimental for CAD. Choice C is incorrect as foods high in fiber, such as fruits, vegetables, and whole grains, are beneficial for heart health. Choice D is incorrect as increasing sodium intake can lead to hypertension and worsen CAD.
A nurse is educating a client on how to use a cane due to left-leg weakness. What should the nurse include in the teaching?
- A. Use the cane on the stronger side
- B. Advance the cane and the weaker leg at the same time
- C. Use the cane on the weaker side
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct Answer: A
Rationale: The correct answer is to use the cane on the stronger side. By doing so, the client will have better support and balance. Choice B is incorrect because advancing the cane and the weaker leg at the same time may lead to instability and falls. Choice C is incorrect as using the cane on the weaker side does not provide optimal support. Choice D is incorrect as advancing the cane 30 to 45 cm (12-18 in) with each step is not a standard recommendation for cane use.
A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?
- A. Providing care in the hallway
- B. Reporting client information in the hallway
- C. Helping another client use the restroom
- D. Feeding the client too quickly
Correct Answer: B
Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.
Which of the following is an early indicator that suctioning is needed for a client with a tracheostomy?
- A. Bradycardia
- B. Hypotension
- C. Irritability
- D. Confusion
Correct Answer: C
Rationale: Irritability is an early indicator that suctioning is needed for a client with a tracheostomy because it can signal discomfort or difficulty breathing due to mucus accumulation, prompting the need for suctioning to clear the airway. Bradycardia (Choice A) and hypotension (Choice B) are not typically early indicators of the need for suctioning in a client with a tracheostomy. Confusion (Choice D) is also not a direct early indicator of the need for suctioning in this context.
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?
- A. Increased speech
- B. Lack of sleep
- C. Agitation
- D. Poor concentration
Correct Answer: B
Rationale: The correct answer is lack of sleep (choice B). In acute mania, lack of sleep can exacerbate symptoms, lead to exhaustion, and pose serious risks to the client's well-being. Addressing the client's sleep deprivation is a priority as it can impact their overall health and recovery. Increased speech (choice A) and agitation (choice C) are common in acute mania but do not pose immediate physical risks like lack of sleep. Poor concentration (choice D) is also a symptom of acute mania but addressing sleep deprivation takes precedence due to its severe consequences.