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The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse?
- A. The client diagnosed with congestive heart failure who is being discharged in the morning.
- B. The client who is having frequent incontinent liquid bowel movements and vomiting.
- C. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62.
- D. The client who is complaining of chest pain on inspiration and a nonproductive cough.
Correct Answer: C
Rationale: Tachycardia, tachypnea, and hypotension (C) suggest instability, requiring experienced nursing care. Discharging CHF (A), incontinence/vomiting (B), and pleuritic pain (D) are less acute.
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Which nursing action can best help reduce the client's anxiety in this situation?
- A. Teach the client how coronary artery disease (CAD) is usually treated.
- B. Listen to the client's feelings about this condition.
- C. Explain that the procedure has been very helpful for other clients.
- D. Avoid discussing the heart catheterization until the client has relaxed.
Correct Answer: B
Rationale: Listening to the client's feelings validates their emotions and reduces anxiety by fostering trust and open communication.
The nursing team develops a care plan and expected outcomes for the client's recovery. Which expected outcomes are most important? Select all that apply.
- A. The client will not gain weight.
- B. The client will not gain weight.
- C. The client will comply with the dietary restrictions.
- D. The client will avoid any alcoholic beverages.
- E. The client will verbalize fears and anxieties freely.
- F. The client will maintain pressure over the intravenous site.
Correct Answer: C,D,E
Rationale: Complying with dietary restrictions, avoiding alcohol, and verbalizing fears support recovery by reducing cardiac risk and addressing emotional needs.
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.
After hearing the nurse's instructions about activity restrictions and the potentially dangerous consequences of certain activities, the client correctly states the importance for avoiding which of the following?
- A. Carrying groceries from the car
- B. Straining during a bowel movement
- C. Bathing in warm water
- D. Having sexual intercourse
Correct Answer: B
Rationale: Straining during a bowel movement increases intrathoracic pressure, raising cardiac workload and MI risk.
A young adult with a history of rheumatic fever as a child is to have a cardiac catheterization. She asks the nurse why she must have a cardiac catheterization. The nurse's response is based on the understanding that cardiac catheterization can accomplish all of the following EXCEPT:
- A. assessing heart structures.
- B. determining oxygen levels in the heart chambers.
- C. evaluating cardiac output.
- D. obtaining a biopsy specimen.
Correct Answer: D
Rationale: Cardiac catheterization can assess heart structures, measure oxygen levels, and evaluate cardiac output, but obtaining a biopsy specimen is not a standard purpose of this procedure. Biopsies are typically performed via other methods, such as endomyocardial biopsy in specific cases.