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The client with a history of left-sided heart failure is exhibiting increasing shortness of breath and frothy sputum. What is the priority nursing action?
- A. Administer oxygen
- B. Encourage coughing and deep breathing
- C. Place the client in a supine position
- D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: Shortness of breath and frothy sputum are indicative of pulmonary edema, a serious condition that requires immediate intervention to improve oxygenation. Administering oxygen is the priority action to support the client's respiratory function and prevent further deterioration. Oxygen therapy helps increase the oxygen levels in the blood, alleviate respiratory distress, and support vital organ function. Prompt intervention with oxygen can help stabilize the client while further assessments and treatments are initiated.
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The nurse is teaching a client with coronary artery disease (CAD) about the risk factors for the disease. Which modifiable risk factor should the nurse emphasize?
- A. Family history
- B. Age
- C. Cigarette smoking
- D. Gender
Correct Answer: C
Rationale: Cigarette smoking is a modifiable risk factor for coronary artery disease (CAD) because it can be changed or controlled to reduce the risk of developing CAD. Family history, age, and gender are non-modifiable risk factors, meaning they cannot be changed. By emphasizing the importance of quitting smoking, the nurse can help the client reduce their risk of CAD and improve their overall cardiovascular health.
A client with a history of coronary artery disease (CAD) is being discharged with a prescription for aspirin. Which instruction should the nurse reinforce with the client?
- A. Take the aspirin on an empty stomach for better absorption.
- B. Stop taking the aspirin if you experience any stomach discomfort.
- C. Take the aspirin with food to reduce the risk of stomach irritation.
- D. Take the aspirin only when you have chest pain.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a diagnosis of angina pectoris is prescribed nitroglycerin. The nurse should teach the client to take the medication in which way?
- A. Take one tablet daily with breakfast
- B. Take one tablet every 5 minutes as needed, up to three times
- C. Take one tablet every hour until pain subsides
- D. Take one tablet only if pain does not subside after 30 minutes
Correct Answer: B
Rationale: Nitroglycerin is a rapid-acting medication used to relieve angina pain by dilating blood vessels. The correct administration is to take one tablet every 5 minutes as needed, up to three doses. If chest pain persists after three doses, the client should seek emergency medical attention as it can indicate a more serious cardiac issue.
The nurse is preparing to administer a scheduled dose of enalapril (Vasotec) to a client with hypertension. Before administering the medication, the nurse should check which priority assessment?
- A. Heart rate
- B. Blood pressure
- C. Respiratory rate
- D. Temperature
Correct Answer: B
Rationale: Before administering enalapril, an antihypertensive medication, the nurse should prioritize checking the client's blood pressure. Monitoring blood pressure helps ensure it is at an acceptable level before giving the medication, as enalapril can further lower blood pressure. This assessment is crucial in preventing potential hypotensive episodes and adverse effects associated with excessive blood pressure reduction.
The client with a history of heart failure is receiving digoxin (Lanoxin). Which electrolyte imbalance increases the risk of digoxin toxicity?
- A. Hypernatremia
- B. Hypercalcemia
- C. Hypokalemia
- D. Hypomagnesemia
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.