Nokea
The best evidence that the client is complying with the diet therapy is the report of using which type of fat for cooking?
- A. Melted margarine
- B. Clarified butter
- C. Cooking spray
- D. Liquid corn oil
Correct Answer: C
Rationale: Cooking spray is low in saturated fat and calories, aligning with a heart-healthy diet to control CAD progression.
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Which statement by the nurse is the best explanation for why the client needs to take the prescribed medication?
- A. It may destroy the virus causing your disease.
- B. It may reduce the scar tissue on the valve.
- C. It may stop blood clots from forming.
- D. It may prevent future bacterial infections.
Correct Answer: D
Rationale: Nafcillin is an antibiotic used to prevent bacterial endocarditis in valvular disease.
To provide adequate care for the client with worsening left-sided heart failure, the intensive care unit (ICU) nurse should be a full of the following on a daily basis?
- A. Pupil response
- B. Peripheral edema
- C. Appetite
- D. Weight
Correct Answer: B,D
Rationale: Peripheral edema and weight are key indicators of fluid status in heart failure.
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply.
- A. Administer morphine intramuscularly.
- B. Administer an aspirin orally.
- C. Apply oxygen via a nasal cannula.
- D. Place the client in a supine position.
- E. Administer nitroglycerin subcutaneously.
Correct Answer: B,C
Rationale: Aspirin (B) reduces clot formation, and oxygen (C) improves myocardial oxygenation. Morphine IM (A) delays absorption, supine position (D) increases preload, and nitroglycerin SC (E) is incorrect; SL is used.
The nurse knows that the client understands how to determine when the nitroglycerin tablets need replacing when the client makes which statement?
- A. The tablets will be discovered.
- B. The tablets will be discolored.
- C. They won't tingle in my mouth.
- D. They will disintegrate when I touch them.
Correct Answer: C
Rationale: Fresh nitroglycerin tablets cause a tingling sensation under the tongue; loss of this sensation indicates loss of potency.
The nurse enters the client's room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. The concept of perfusion is identified by the nurse. Which should the nurse implement first?
- A. Notify the health care provider.
- B. Call a rapid response team (RRT).
- C. Determine the telemetry monitor reading.
- D. Push the Code Blue button.
Correct Answer: D
Rationale: No pulse/respirations indicate cardiac arrest; pushing the Code Blue button (D) initiates the code team. Notifying HCP (A), RRT (B), or checking telemetry (C) delay resuscitation.