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The client tells the nurse of being extremely frightened. What is the most appropriate action for the nurse to take at this time?
- A. Stay with the client.
- B. Explain the procedures.
- C. Tell the client it will be fine.
- D. Record the collected data.
Correct Answer: A
Rationale: Staying with the client provides emotional support, reducing fear during a crisis.
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When the client asks the nurse how propranolol helps to prevent angina, what is the best explanation?
- A. Propranolol promotes excretion of body fluid.
- B. Propranolol reduces the rate of heart contraction.
- C. Propranolol alters pain receptors in the heart.
- D. Propranolol dilates the major coronary arteries.
Correct Answer: B
Rationale: Propranolol, a beta-blocker, reduces heart rate and contractility, decreasing myocardial oxygen demand and preventing angina.
An older adult is admitted to the hospital with symptoms of severe dyspnea, orthopnea, diaphoresis, bubbling respirations, and cyanosis. He states that he is afraid 'something bad is about to happen.' How should the nurse position this client?
- A. Sitting upright
- B. Head lower than feet
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sitting upright reduces pulmonary congestion and improves breathing in clients with acute heart failure symptoms like dyspnea and orthopnea.
The nurse is caring for an elderly client who has congestive heart failure and is taking digoxin. The client should be monitored for which of the following signs of toxicity?
- A. Disorientation
- B. Weight gain
- C. Constipation
- D. Dyspnea
Correct Answer: A
Rationale: Disorientation is a neurological sign of digoxin toxicity. Weight gain, constipation, and dyspnea are not specific to digoxin toxicity.
Which assessment finding should signal the nurse to withhold applying the client's nitroglycerin patch and notify the physician?
- A. The pressure of 99.8°F (37.6°C)
- B. Respiratory rate of 24 breaths/minute at rest
- C. Apical heart rate of 90 beats/minute
- D. Blood pressure of 94/62 mm Hg
Correct Answer: D
Rationale: A blood pressure of 94/62 mm Hg indicates hypotension, a contraindication for nitroglycerin, which can further lower blood pressure.
If the chest pain is not relieved after taking one nitroglycerin tablet, the nurse should teach the client to take what action?
- A. Take another tablet in 5 minutes.
- B. The nurse is the energy department.
- C. Call the physician immediately.
- D. Swallow two additional tablets.
Correct Answer: A
Rationale: If angina persists after one nitroglycerin tablet, another can be taken every 5 minutes up to three doses, then seek medical help if unrelieved.