Nokea
The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client?
- A. Instruct the client to use a soft-bristle toothbrush.
- B. Discuss the importance of getting a monthly partial thromboplastin time (PTT).
- C. Teach the client about signs of pacemaker malfunction.
- D. Explain to the client the procedure for synchronized cardioversion.
Correct Answer: A
Rationale: Atrial fibrillation requires anticoagulation, increasing bleeding risk; a soft-bristle toothbrush (A) prevents gum bleeding. PTT (B) monitors heparin, not warfarin, pacemakers (C) are unrelated, and cardioversion (D) is not routine.
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Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply.
- A. Encourage a low-fat, low-cholesterol diet.
- B. Instruct the client to walk 30 minutes a day.
- C. Decrease the salt intake to two (2) g a day.
- D. Refer to a counselor for stress reduction techniques.
- E. Teach the client to increase fiber in the diet.
Correct Answer: A,B,D,E
Rationale: Low-fat/cholesterol diet (A), walking (B), stress reduction (D), and high-fiber diet (E) reduce CAD risk. Salt restriction (C) is more specific to CHF or hypertension.
The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?
- A. Administer sublingual nitroglycerin.
- B. Obtain a STAT electrocardiogram (ECG).
- C. Have the client sit down immediately.
- D. Assess the client's vital signs.
Correct Answer: C
Rationale: Activity-related chest pain suggests ischemia. Having the client sit (C) stops exertion, reducing oxygen demand. Nitroglycerin (A), ECG (B), and vital signs (D) follow.
Which client problem has priority for the client with a cardiac dysrhythmia?
- A. Alteration in comfort.
- B. Decreased cardiac output.
- C. Impaired gas exchange.
- D. Activity intolerance.
Correct Answer: B
Rationale: Dysrhythmias primarily reduce cardiac output (B), impacting perfusion, making it the priority. Comfort (A), gas exchange (C), and activity (D) are secondary.
Which nursing diagnosis would be priority for the client diagnosed with myocarditis?
- A. Anxiety related to possible long-term complications.
- B. High risk for injury related to antibiotic therapy.
- C. Increased cardiac output related to valve regurgitation.
- D. Activity intolerance related to impaired cardiac muscle function.
Correct Answer: D
Rationale: Myocarditis impairs cardiac function, making activity intolerance (D) the priority due to reduced cardiac output. Anxiety (A), injury (B), and increased output (C) are less immediate or incorrect.
The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching?
- A. The client takes prophylactic antibiotics.
- B. The client uses a soft-bristle toothbrush.
- C. The client takes an enteric-coated aspirin daily.
- D. The client alternates rest with activity.
Correct Answer: C
Rationale: Aspirin (C) is not routinely required post-mechanical valve; warfarin is standard. Antibiotics (A), soft toothbrush (B), and rest/activity (D) are appropriate.