Nokea
Before administering the digoxin (Lanoxin) to the client, what nursing assessment is essential?
- A. The client's heart rate
- B. The client's blood pressure
- C. The client's heart sounds
- D. The client's breath sounds
Correct Answer: A
Rationale: Check heart rate; withhold digoxin if <60 bpm to prevent toxicity.
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A male client with angina pectoris has been having an increased number of episodes of pain recently. He is admitted for observation. During the admission interview, he tells the nurse that he has been having chest pain during the last week. Which statement by the client would be of greatest concern to the nurse?
- A. I had chest pain while I was walking in the snow on Thursday.'
- B. We went out for a big dinner to celebrate my wife's birthday, but I couldn't enjoy it because I got the pain before we got home from the restaurant.'
- C. I had chest pain yesterday while I was sitting in the living room watching television.'
- D. I felt pain all the way down my left arm after I was playing with my grandson on Monday.'
Correct Answer: C
Rationale: Chest pain at rest, such as while watching television, is concerning as it may indicate unstable angina or impending myocardial infarction, requiring urgent evaluation. Pain with activity, eating, or radiating to the arm is typical of angina but less immediately alarming.
During the postoperative period, what is the best rationale for the nurse frequently assessing the client's fluid status?
- A. Urine retention is common after a heart transplant.
- B. Urine output is an indication of perfusion to the kidneys.
- C. Hydration determines when the client needs to be transfused.
- D. Hydration indicates when fluids should be increased.
Correct Answer: B
Rationale: Urine output reflects renal perfusion, critical post-heart transplant to monitor graft function.
The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first?
- A. Administer amiodarone, an antidysrhythmic, IVP.
- B. Prepare to defibrillate the client.
- C. Assess the client's apical pulse and blood pressure.
- D. Start basic cardiopulmonary resuscitation.
Correct Answer: C
Rationale: Ventricular tachycardia requires assessing pulse/BP (C) to determine if it’s pulseless (defibrillation, B) or stable (amiodarone, A). CPR (D) is for pulseless states.
If the client's pain is due to a myocardial infarction (MI), which prescribed medication would be most helpful?
- A. A nonsteroidal anti-inflammatory drug such as ibuprofen (Advil)
- B. A nonsalicylate such as acetaminophen (Tylenol)
- C. A salicylate such as aspirin
- D. An opioid such as morphine sulfate
Correct Answer: C
Rationale: Aspirin is critical in MI to inhibit platelet aggregation and prevent further thrombus formation.
The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client?
- A. Apical pulse rate of 110 and 4+ pitting edema of feet.
- B. Thick white sputum and crackles that clear with cough.
- C. The client sleeping with no pillow and eupnea.
- D. Radial pulse rate of 90 and CRT less than three (3) seconds.
Correct Answer: A
Rationale: CHF exacerbation causes fluid overload, leading to tachycardia (apical pulse 110) and severe edema (4+ pitting, A). Thick sputum/crackles (B) suggest pneumonia, sleeping flat with eupnea (C) is unlikely, and normal CRT (D) doesn’t reflect CHF severity.