Nokea
The best evidence that the client understands the nurse's instructions regarding dietary restrictions is if the client states to avoid which food?
- A. Canned soup
- B. Fresh fruit
- C. Baked chicken
- D. Whole grain bread
Correct Answer: A
Rationale: Canned soup is high in sodium, which should be avoided in a low-sodium diet for hypertension management. The other options are generally low-sodium and suitable.
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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.
The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement?
- A. Assess the apical heart rate for one (1) full minute.
- B. Notify the client's cardiac surgeon.
- C. Prepare the client for synchronized cardioversion.
- D. Determine if the client is having pain.
Correct Answer: D
Rationale: Sinus tachycardia post-CABG is often due to pain (D), which should be assessed first. Heart rate (A), notifying (B), and cardioversion (C) follow if needed.
A client is being seen in the clinic to rule out (R/O) mitral valve stenosis. Which assessment data would be most significant?
- A. The client complains of shortness of breath when walking.
- B. The client has jugular vein distention and 3+ pedal edema.
- C. The client complains of chest pain after eating a large meal.
- D. The client's liver is enlarged and the abdomen is edematous.
Correct Answer: A
Rationale: Shortness of breath on exertion (A) is a hallmark of mitral valve stenosis due to impaired left atrial emptying. JVD/edema (B), postprandial pain (C), and liver/abdominal edema (D) suggest right-sided failure or other causes.
Which risk factor is least likely to have predisposed the client to having a myocardial infarction (MI)?
- A. Smoking cigarettes
- B. Eating fatty foods
- C. Working under emotional stress
- D. Drinking an occasional cocktail
Correct Answer: D
Rationale: Occasional alcohol consumption is the least significant MI risk factor compared to smoking, high-fat diets, and chronic stress.
The nurse knows that the client understands the physician's explanation of the PTCA procedure when the client makes which statement?
- A. A balloon-tipped catheter will be inserted into my coronary artery.
- B. A Teflon graft will be used to replace an area of my artery.
- C. A section of my leg vein will be grafted around a narrowed coronary artery.
- D. A battery-operated pacemaker will be implanted to maintain my heart rate.
Correct Answer: A
Rationale: PTCA involves inflating a balloon-tipped catheter to open a narrowed coronary artery, improving blood flow.