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A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. What action should the nurse take?
- A. Obtain a prescription for pain medication.
- B. Have the client stop and lie back down in bed.
- C. Report the complaint to the healthcare provider.
- D. Instruct the client to continue getting out of bed and into a chair.
Correct Answer: B
Rationale: When a client with CAD experiences chest pain, it indicates myocardial ischemia. The nurse should have the client stop the activity and lie back down in bed to reduce the heart's oxygen demand, decrease myocardial workload, and prevent further ischemia. This action helps in improving blood flow to the heart and can potentially alleviate the chest pain.
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After returning the client to bed following a cardiac catheterization procedure with the left femoral vessel as the access site, the nurse places a sign above the bed instructing the client to remain on bed rest and in which position?
- A. In semi-Fowler's position
- B. With the head of the bed elevated 45 degrees
- C. With the head of the bed elevated no more than 15 degrees
- D. With the foot of the bed elevated as much as tolerated by the client
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse implement when providing care for the client?
- A. Take daily weights and monitor trends.
- B. Encourage fluid intake to improve hydration.
- C. Elevate the legs above the level of the heart.
- D. Position the client supine with the head of the bed at 30 degrees.
Correct Answer: A
Rationale: Elevated BNP levels are indicative of heart failure, which often causes fluid retention and weight gain. Taking daily weights and monitoring trends allows the nurse to assess for changes in fluid status. This intervention helps in evaluating the effectiveness of the treatment plan and identifying worsening heart failure symptoms early.
An ambulatory clinic nurse is interviewing a client who is complaining of flu-like symptoms. The client suddenly develops chest pain. Which question best assists the nurse in discriminating pain caused by a non-cardiac problem?
- A. Can you describe the pain to me?
- B. Have you ever had this pain before?
- C. Does the pain get worse when you breathe in?
- D. Can you rate the pain on a scale of 1 to 10, with 10 being the worst?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which intervention to effectively accomplish this goal?
- A. Provide a quiet and low-stimulus environment.
- B. Encourage the family to come visit very frequently.
- C. Encourage the client to call friends and relatives each day.
- D. Recommend that the client watch TV as a constant diversion.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client with Raynaud's phenomenon is being taught by the nurse about preventing episodes. Which instruction should the nurse reinforce?
- A. Wear gloves in cold weather.
- B. Avoid caffeine and chocolate.
- C. Increase intake of vitamin C.
- D. Use a heating pad for warmth.
Correct Answer: A
Rationale: Wearing gloves in cold weather is essential for preventing vasoconstriction and subsequent episodes of Raynaud's phenomenon. Cold temperatures can trigger vasospasms in individuals with Raynaud's, and wearing gloves helps maintain warmth and prevent the constriction of blood vessels in the extremities, reducing the likelihood of an episode.