Nokea
A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?
- A. Do you have trouble breathing or chest pain?
- B. Are you able to walk upstairs without fatigue?
- C. Do you awake with breathlessness during the night?
- D. Do you have new-onset heaviness in your legs?
Correct Answer: B
Rationale: The correct answer is B because assessing the client's ability to walk upstairs without fatigue helps determine the extent of heart failure. This question assesses the client's functional capacity and exercise tolerance, which are key indicators of heart failure severity. If the client experiences fatigue while walking upstairs, it indicates decreased cardiac output and potential heart failure progression. Other choices are incorrect as they focus on symptoms (A), nocturnal dyspnea (C), and peripheral edema (D), which may be present in heart failure but do not directly assess the extent of heart failure like exercise tolerance does.
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What is the definition of blindness in terms of the best corrected visual acuity (BCVA)?
- A. Less than 20/200 even with correction
- B. Between 20/70 and 20/200 in the better eye with glasses
- C. 20/400 or greater with no light perception
- D. 20/40 in at least one eye with correction
Correct Answer: A
Rationale: Blindness is legally defined as BCVA less than 20/200 in the better eye with correction.
How does the pain of a myocardial infarction (MI) differ from stable angina?
- A. Accompanied by shortness of breath
- B. Feelings of fear or anxiety
- C. Lasts less than 15 minutes
- D. No relief from taking nitroglycerin
Correct Answer: C
Rationale: The correct answer is C because the pain of a myocardial infarction (MI) typically lasts longer than 15 minutes, unlike stable angina which lasts for a shorter duration. MI pain is usually described as intense, crushing, and prolonged, whereas stable angina pain is often triggered by exertion and relieved by rest or medication like nitroglycerin. Choices A, B, and D are incorrect because shortness of breath, feelings of fear or anxiety, and lack of relief from nitroglycerin are not definitive differentiating factors between MI and stable angina.
Prior to a cardiac catheterization, what is the most important action for the nurse to take?
- A. Ensure that the client has been NPO for 6 hours before the procedure.
- B. Administer pre-procedure medications as ordered.
- C. Verify that informed consent has been obtained.
- D. Assess the client for any allergies, especially to iodine or shellfish.
Correct Answer: D
Rationale: The correct answer is D: Assess the client for any allergies, especially to iodine or shellfish. This is crucial because contrast dye containing iodine is commonly used during cardiac catheterization, and a client with allergies to iodine or shellfish can have a severe allergic reaction. It is essential to identify allergies beforehand to prevent any potential adverse reactions during the procedure.
A: Ensuring NPO status is important for some procedures, but assessing for allergies is more critical to prevent life-threatening reactions.
B: Administering pre-procedure medications is important, but assessing for allergies takes precedence to avoid allergic reactions.
C: While obtaining informed consent is necessary, assessing for allergies is a crucial safety measure to prevent allergic reactions during the procedure.
After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?
- A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
- B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
- C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
- D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.
Correct Answer: C
Rationale: Step 1: Wheezes indicate narrowing of the airways, typically seen in conditions like asthma.
Step 2: Inhaled bronchodilators help dilate the airways, relieving wheezing and improving breathing.
Step 3: Hence, administering an inhaled bronchodilator is the correct intervention for wheezes.
Summary:
A: Increasing oxygen flow does not directly address the issue of wheezes.
B: Encouraging coughing does not address the narrowing of airways seen with wheezes.
D: Deep breathing does not specifically target the narrowing of airways associated with wheezes.
A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?
- A. Assess the client's lung sounds.
- B. Call the Rapid Response Team.
- C. Have the client sit upright.
- D. Listen to the client's lung sounds.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's lung sounds. This is important because after a myocardial infarction, there is a risk of pulmonary edema, which can present as crackles or wheezes in the lungs. By assessing the lung sounds, the healthcare provider can identify any signs of respiratory distress and promptly intervene if necessary.
Choice B is incorrect because calling the Rapid Response Team is not warranted based solely on abnormal heart sounds. Choice C is incorrect as having the client sit upright is not directly related to addressing abnormal heart sounds. Choice D is also incorrect as it focuses solely on assessing lung sounds without considering the potential implications of the abnormal heart sounds.