Nokea
A client with myocardial infarction underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider about resuming sexual relations. What teaching should the nurse reinforce with this client?
- A. Client may be ready for sexual activity if no symptoms occur when climbing 2 flights of stairs
- B. Client will be ready for sexual activity after completion of cardiac rehabilitation
- C. It will be 6 months before the heart is healthy enough for sexual activity
- D. Medications such as sildenafil or tadalafil are available as prescriptions from the health care provider
Correct Answer: A
Rationale: Climbing two flights of stairs without symptoms indicates sufficient cardiac reserve for sexual activity. Waiting for rehab completion or 6 months is unnecessary, and medications require provider discussion.
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The nurse is assisting in caring for a client who had a transsphenoidal hypophysectomy 48 hours ago and has developed diabetes insipidus. Which of the following prescriptions should the nurse clarify?
- A. Administer desmopressin
- B. Check the client's urine osmolarity daily
- C. Obtain a blood specimen to check the serum sodium level
- D. Place the client in Trendelenburg position
Correct Answer: D
Rationale: Desmopressin treats diabetes insipidus by replacing vasopressin. Checking urine osmolarity and serum sodium monitors the condition. Trendelenburg position is inappropriate as it may increase intracranial pressure post-hypophysectomy.
All of the following clients are on the unit. Which one is most likely to develop urinary retention?
- A. A woman who had a modified radical mastectomy yesterday
- B. A man who had an abdominal cholecystectomy this morning
- C. A woman who had an abdominal hysterectomy yesterday
- D. A man who had surgery for a ruptured appendix
Correct Answer: C
Rationale: Abdominal hysterectomy involves pelvic manipulation, increasing urinary retention risk due to bladder trauma or nerve disruption. Other surgeries pose lower risk.
Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
- A. Venturi mask
- B. Partial rebreather mask
- C. Non-rebreather mask
- D. Simple face mask
Correct Answer: C
Rationale: Non-rebreather mask. The non-rebreather mask has a one-way valve that prevents exhaled air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of the oxygen is available.
The nurse is talking with a client with major depressive disorder who is receiving isocarboxazid. Which of the following statements by the client would be a priority to follow up?
- A. I am feeling fatigued at the end of most days.
- B. I have been experiencing constipation recently
- C. I have been gaining weight since I started taking the medication
Correct Answer: A
Rationale: Fatigue may indicate worsening depression or MAOI side effects, requiring urgent follow-up. Constipation and weight gain are common but less critical.
After obtaining a nutritional assessment of an elderly client, the nurse determines that the client's diet lacks sufficient protein. Which foods represent low-cost sources of protein?
- A. Potatoes and beef
- B. Peas and beans
- C. Tomatoes and beets
- D. Pork and rice
Correct Answer: B
Rationale: Peas and beans are low-cost, high-protein foods. Beef and pork are expensive, and potatoes, tomatoes, beets, and rice are low in protein.