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An ambulatory clinic nurse is interviewing a client who is complaining of flu-like symptoms. The client suddenly develops chest pain. Which question best assists the nurse in discriminating pain caused by a non-cardiac problem?
- A. Can you describe the pain to me?
- B. Have you ever had this pain before?
- C. Does the pain get worse when you breathe in?
- D. Can you rate the pain on a scale of 1 to 10, with 10 being the worst?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is informed during shift report that a client is experiencing occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development?
- A. Hypokalemia
- B. Hypernatremia
- C. Hypochloremia
- D. Hypercalcemia
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The LPN/LVN is reinforcing instructions to a client on the use of a metered-dose inhaler. The nurse should recognize that the client is using the inhaler correctly if the client takes which action?
- A. Takes a deep breath and then exhales just before administration
- B. Holds the mouthpiece 1 to 2 inches from the mouth
- C. Inhales the medication and then exhales immediately after administration
- D. Performs 3 short inhalations and then exhales deeply after administration
Correct Answer: A
Rationale: When using a metered-dose inhaler, the client should take a deep breath and then exhale just before administration. This technique helps ensure that the medication is inhaled effectively. By exhaling before administration, the client can fully inhale the medication into the lungs, maximizing its therapeutic effects.
Before administering digoxin (Lanoxin) to a client diagnosed with heart failure, the nurse should perform which assessment?
- A. Check the blood pressure.
- B. Obtain an electrocardiogram (ECG).
- C. Assess the apical pulse.
- D. Review the latest electrolyte levels.
Correct Answer: C
Rationale: Assessing the apical pulse is crucial before administering digoxin because the medication can lead to bradycardia. Monitoring the apical pulse helps determine the heart rate, and digoxin is typically withheld if the pulse is below 60 beats per minute. This assessment is essential to prevent potential adverse effects associated with digoxin administration.
The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which intervention to effectively accomplish this goal?
- A. Provide a quiet and low-stimulus environment.
- B. Encourage the family to come visit very frequently.
- C. Encourage the client to call friends and relatives each day.
- D. Recommend that the client watch TV as a constant diversion.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client admitted to the hospital with pulmonary edema is preparing for discharge. The client should be reminded of the importance of complying with which measure to prevent a recurrence?
- A. Weigh oneself every morning before breakfast.
- B. Sleep with the head elevated on multiple pillows.
- C. Adjust diuretic dose without healthcare provider guidance.
- D. Take additional digoxin (Lanoxin) as a preventive measure.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.