Nokea
If the heart murmur is related to valve damage caused by a childhood infection, the nurse would expect the client to report having had which disease?
- A. Varicella (chickenpox)
- B. Measles
- C. Rheumatic fever
- D. Whooping cough
Correct Answer: C
Rationale: Rheumatic fever is associated with valvular damage due to streptococcal infection.
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The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?
- A. Sponge the client's forehead.
- B. Obtain a pulse oximetry reading.
- C. Take the client's vital signs.
- D. Assist the client to a sitting position.
Correct Answer: D
Rationale: Gasping, clamminess, and cyanosis indicate acute pulmonary edema. Sitting upright (D) improves breathing by reducing preload. Sponging (A), pulse oximetry (B), and vital signs (C) are secondary to positioning.
An older adult is scheduled for coronary arteriography during a cardiac catheterization. Which nursing intervention will be essential as she recovers from the diagnostic procedure on the hospital unit?
- A. Encouraging frequent ambulation to prevent deep vein thrombosis
- B. Limiting fluid intake to prevent fluid overload
- C. Limiting dietary fiber to prevent diarrhea
- D. Assessing the arterial puncture site when taking vital signs
Correct Answer: D
Rationale: Assessing the arterial puncture site is essential to detect complications like bleeding or hematoma post-coronary arteriography.
Before the cardiac catheterization and coronary arteriogram, it is essential for the nurse will be taken about any allergy to iodine or which other substance?
- A. Penicillin
- B. Morphine
- C. Shellfish
- D. Eggs
Correct Answer: C
Rationale: Shellfish allergies often indicate a risk of iodine sensitivity, which is critical since contrast dye used in arteriograms contains iodine.
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.
The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include?
- A. Instruct the client to take a cough suppressant if a cough develops.
- B. Teach the client how to prevent orthostatic hypotension.
- C. Encourage the client to eat bananas to increase potassium level.
- D. Explain the importance of taking the medication with food.
Correct Answer: B
Rationale: ACE inhibitors cause hypotension, so teaching prevention of orthostatic hypotension (B) is critical. Cough suppressants (A) are inappropriate for ACE inhibitor cough, bananas (C) are unnecessary unless hypokalemia exists, and food (D) is not required.