Nokea
An older adult is admitted to the hospital with symptoms of severe dyspnea, orthopnea, diaphoresis, bubbling respirations, and cyanosis. He states that he is afraid 'something bad is about to happen.' How should the nurse position this client?
- A. Sitting upright
- B. Head lower than feet
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sitting upright reduces pulmonary congestion and improves breathing in clients with acute heart failure symptoms like dyspnea and orthopnea.
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Which nursing action is most appropriate to perform next?
- A. The nurse notifies the physician, requesting a hypnotic or sedative.
- B. The nurse provides a video of the surgery for the client to watch.
- C. The nurse waits until the client's spouse is present to excessive the surgery.
- D. The nurse listens as the client talks about fears concerning surgery and rehabilitation.
Correct Answer: D
Rationale: Listening to the client's fears reduces anxiety and supports emotional preparation for surgery.
Digoxin (Lanoxin) and furosemide (Lasix) are ordered for a client who has congestive heart failure. Which of the following would the nurse also expect to be ordered for this client?
- A. Potassium
- B. Calcium
- C. Aspirin
- D. Coumadin
Correct Answer: A
Rationale: Furosemide, a diuretic, can cause potassium loss, leading to hypokalemia, which increases the risk of digoxin toxicity. Potassium supplements are often ordered to maintain normal levels.
When the client asks the nurse how propranolol helps to prevent angina, what is the best explanation?
- A. Propranolol promotes excretion of body fluid.
- B. Propranolol reduces the rate of heart contraction.
- C. Propranolol alters pain receptors in the heart.
- D. Propranolol dilates the major coronary arteries.
Correct Answer: B
Rationale: Propranolol, a beta-blocker, reduces heart rate and contractility, decreasing myocardial oxygen demand and preventing angina.
Which laboratory results would the nurse expect to be elevated if the client had a myocardial infarction (MI)?
- A. Isoenzymes and troponin
- B. Sodium and potassium
- C. Red blood cells and platelets
- D. Plasminogen and lactic acid
Correct Answer: A
Rationale: Troponin and cardiac isoenzymes (e.g., CK-MB) are specific markers of myocardial damage in MI.
What is the best explanation for the drug therapy in this situation?
- A. Aspirin tends to relieve chest pain.
- B. Aspirin tends to prevent blood clots.
- C. Aspirin tends to lower the blood pressure.
- D. Aspirin tendsmedi tends to dilate the coronary arteries.
Correct Answer: B
Rationale: Aspirin's antiplatelet effect prevents thrombus formation at the PTCA site, reducing the risk of re-occlusion.