Nokea
After hearing the nurse's instructions about activity restrictions and the potentially dangerous consequences of certain activities, the client correctly states the importance for avoiding which of the following?
- A. Carrying groceries from the car
- B. Straining during a bowel movement
- C. Bathing in warm water
- D. Having sexual intercourse
Correct Answer: B
Rationale: Straining during a bowel movement increases intrathoracic pressure, raising cardiac workload and MI risk.
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A young adult with a history of rheumatic fever as a child is to have a cardiac catheterization. She asks the nurse why she must have a cardiac catheterization. The nurse's response is based on the understanding that cardiac catheterization can accomplish all of the following EXCEPT:
- A. assessing heart structures.
- B. determining oxygen levels in the heart chambers.
- C. evaluating cardiac output.
- D. obtaining a biopsy specimen.
Correct Answer: D
Rationale: Cardiac catheterization can assess heart structures, measure oxygen levels, and evaluate cardiac output, but obtaining a biopsy specimen is not a standard purpose of this procedure. Biopsies are typically performed via other methods, such as endomyocardial biopsy in specific cases.
Which data would cause the nurse to question administering digoxin to a client diagnosed with congestive heart failure?
- A. The potassium level is 3.2 mEq/L.
- B. The digoxin level is 1.2 mcg/mL.
- C. The client's apical pulse is 64.
- D. The client denies yellow haze.
Correct Answer: A
Rationale: Hypokalemia (K+ 3.2, A) increases digoxin toxicity risk, warranting caution. Digoxin level 1.2 (B) is therapeutic, pulse 64 (C) is normal, and no yellow haze (D) is expected.
If the client's severe chest pain is typical of other people who experience myocardial infarction (MI), the client is most likely to tell the nurse that the discomfort radiates to which area?
- A. Flank
- B. Groin
- C. Abdomen
- D. Shoulder
Correct Answer: D
Rationale: MI pain typically radiates to the shoulder, arm, or jaw due to referred pain from cardiac ischemia.
The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?
- A. Call a code immediately.
- B. Assess the client for a pulse.
- C. Begin chest compressions.
- D. Continue to monitor the client.
Correct Answer: B
Rationale: Ventricular tachycardia requires assessing for a pulse (B) to determine if it’s pulseless (needing CPR, C) or stable (medication). Calling a code (A) or monitoring (D) depends on pulse status.
The nurse informs the client that the correct way to administer nitroglycerin is to place one tablet where?
- A. The nurse is the first and check
- B. At the back of the throat
- C. Under the tongue
- D. Between the teeth
Correct Answer: C
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption into the bloodstream to relieve angina.