Nokea
An adult client with peripheral vascular disease tells the nurse he is afraid his left leg is not improving and may need to be amputated. How should the nurse respond?
- A. You and your wife should discuss your feelings before surgery.'
- B. You sound concerned about your leg and possible surgery.'
- C. It is better to have an amputation when the ulcers are not improving.'
- D. You don't need to be afraid of surgery.'
Correct Answer: B
Rationale: Reflecting the client’s concern encourages open communication and validates his feelings, promoting therapeutic dialogue.
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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.
When gathering nursing assessment data, which finding will adults with chronic cardiac diseases most frequently, the client is a good treatment.
- A. Barrel-shaped chest
- B. Flushed facial skin
- C. Clubbed fingertips
- D. Chest pain
Correct Answer: C
Rationale: Clubbed fingertips are common in chronic cardiac diseases due to chronic hypoxia.
The nurse is preparing a client for a cardiac catheterization. Which action would the nurse expect to take?
- A. Administer a radioisotope as ordered.
- B. Give the client a cleansing enema.
- C. Locate and mark peripheral pulses.
- D. Encourage high fluid intake before the test.
Correct Answer: C
Rationale: Locating and marking peripheral pulses before cardiac catheterization allows for post-procedure comparison to detect complications like arterial occlusion. Radioisotopes, enemas, and high fluid intake are not standard preparations for this procedure.
As part of the discharge instructions, the nurse correctly instructs the client that which symptom is a sign of artificial pacemaker malfunction?
- A. Tingling in the chest area
- B. Dizziness during activity
- C. Pain radiating to the arm
- D. Tenderness beneath the skin
Correct Answer: B
Rationale: Dizziness during activity may indicate pacemaker failure to maintain adequate heart rate.
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.