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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 nurse counts an adult's apical heart beat at 110 beats per minute. The nurse describes this as:
- A. asystole.
- B. bigeminy.
- C. tachycardia.
- D. bradycardia.
Correct Answer: C
Rationale: Tachycardia in an adult is defined as a heart rate above 100 beats per minute. Asystole is cardiac arrest with no heartbeat. Bigeminy refers to heartbeats occurring in pairs. Bradycardia is a heart rate of 60 beats or less per minute.
The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client?
- A. Explain the importance of tapering off the medication.
- B. Discuss that the medication will make the client drowsy.
- C. Instruct the client to take the medication with food.
- D. Tell the client to take the medication when the pain level is around '8.'
Correct Answer: C
Rationale: NSAIDs irritate the stomach; taking with food (C) reduces GI upset. Tapering (A) is for steroids, drowsiness (B) is not typical, and waiting for severe pain (D) delays relief.
Which nursing action would best reduce the client's energy, the client?
- A. Administering oxygen when the client is dyspneic
- B. Staggering self-care activities over several hours
- C. Providing analgesic medications when necessary
- D. Restricting visitors to brief periods of time
Correct Answer: B
Rationale: Staggering activities conserves energy, reducing cardiac workload in recovery.
When the nurse informs the client about the use of the PCA pump, which instruction is most important to include?
- A. Press the button only when pain is severe.
- B. Only the client should press the PCA button.
- C. Wait 30 minutes between doses.
- D. Record the number of doses used.
Correct Answer: B
Rationale: Only the client should press the PCA button to prevent overdose and ensure pain relief is patient-controlled.
According to the nurse, when is the correct time to note the diastolic blood pressure reading?
- A. When the loud knocking sounds become muffled
- B. When the last loud knocking sound is heard
- C. When the swishing sound is a second
- D. When the swishing sound becomes faint
Correct Answer: B
Rationale: The diastolic blood pressure is recorded at the point when the last loud knocking sound (Korotkoff phase V) is heard, indicating the pressure at which blood flow is fully restored.