Nokea
A low-sodium, low-cholesterol, weight-reducing diet is prescribed for an adult with heart disease. The nurse knows that he understands his diet when he chooses which of the following meals?
- A. Baked skinless chicken and mashed potatoes
- B. Stir-fried Chinese vegetables and rice
- C. Tuna fish salad with celery sticks
- D. Grilled lean steak Ascertainly grilled lean steak with carrots
Correct Answer: A
Rationale: Baked skinless chicken and mashed potatoes are low in sodium and cholesterol, making them suitable for a heart-healthy diet. Stir-fried vegetables may contain high sodium sauces, tuna salad may include high-sodium dressings, and grilled steak is higher in cholesterol.
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Which finding best indicates that cardiac compressions can be discontinued?
- A. The victim's color improves.
- B. The pupils become dilated.
- C. A pulse can be palpated.
- D. The victim begins to vomit.
Correct Answer: C
Rationale: A palpable pulse indicates spontaneous circulation, allowing CPR to be discontinued.
The nurse provides discharge instructions for a client who has recovered after a cardiac catheterization. Which instructions should be included? Select all that apply.
- A. Take a shower rather than a tub bath until the puncture site heals.
- B. Perform leg exercises every 2 hours while awake.
- C. In the generous amount of fluids for the next 24 hours.
- D. Report worsening of pain in the leg that was catheterized.
- E. Flush the toilet twice after eliminating urine and stool in the next 24 hours.
- F. Change the dressing over the puncture site daily until it heals.
Correct Answer: A,C,D
Rationale: Showering prevents infection, generous fluids help flush contrast dye, and reporting worsening pain detects complications. Leg exercises, double flushing, and daily dressing changes are not standard.
Which value should the nurse report immediately to the physician?
- A. Sodium: 137 mEq/L
- B. Potassium: 2.5 mEq/L
- C. Chloride: 97 mEq/L
- D. Bicarbonate: 25 mEq/L
Correct Answer: B
Rationale: Potassium of 2.5 mEq/L (hypokalemia) is critical, especially with diuretics, risking arrhythmias.
The nurse is caring for an elderly client who has congestive heart failure and is taking digoxin. The client should be monitored for which of the following signs of toxicity?
- A. Disorientation
- B. Weight gain
- C. Constipation
- D. Dyspnea
Correct Answer: A
Rationale: Disorientation is a neurological sign of digoxin toxicity. Weight gain, constipation, and dyspnea are not specific to digoxin toxicity.
The nurse checking the client's leg incision is aware that which is the most common blood vessel used in CABG surgery?
- A. The saphenous vein
- B. The femoral artery
- C. The popliteal vein
- D. The iliac artery
Correct Answer: A
Rationale: The saphenous vein is commonly used in CABG due to its accessibility and suitability for grafting.