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During the admission interview, a client who is admitted for a cardiac catheterization says, 'Every time I eat shrimp I get a rash.' What action is essential for the nurse to take at this time?
- A. Notify the physician.
- B. Ask the client if she gets a rash from any other foods.
- C. Instruct the dietary department not to give the client shrimp.
- D. Teach the client the dangers of eating shrimp and other shellfish.
Correct Answer: A
Rationale: A shrimp allergy may indicate an iodine allergy, as shellfish contain iodine, which is also present in the dye used for cardiac catheterization. Notifying the physician is essential to assess the risk and consider alternative dyes or premedication. Asking about other foods, instructing the dietary department, or teaching about shellfish dangers are secondary actions.
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The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching?
- A. Do you have a daily bowel movement?'
- B. Do you get yearly chest x-rays (CXRs)?'
- C. Are you sexually active?'
- D. Have you had any weight change?'
Correct Answer: D
Rationale: Weight change (D) may indicate fluid retention or malnutrition, relevant to CAD management. Bowel movements (A), CXRs (B), and sexual activity (C) are less directly related.
Which assessment finding documented by the nurse provides the best evidence that the client has a bacterial infection?
- A. Chest pain
- B. Dry cough
- C. Fever
- D. Dyspnea
Correct Answer: C
Rationale: Fever is a hallmark of bacterial infection, such as in endocarditis.
Which symptom would the nurse expect to observe if the client is having an allergic reaction to streptokinase (Streptase)?
- A. Urticaria
- B. Anuria
- C. Hemoptysis
- D. Dyspepsia
Correct Answer: A
Rationale: Urticaria (hives) is a common sign of an allergic reaction to streptokinase, a thrombolytic agent.
What should be included in foot care for the client who has a peripheral vascular disorder?
- A. Soaking the feet for 20 minutes before washing them
- B. Walking barefoot only on carpeted floors
- C. Applying lotion between the toes to avoid cracking of the skin
- D. Avoiding exposure of the legs and feet to the sun
Correct Answer: D
Rationale: Avoiding sun exposure prevents skin damage in clients with compromised circulation due to peripheral vascular disease. Soaking, walking barefoot, or applying lotion between toes increase infection or injury risk.
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.