Nokea
The client with a mechanical valve replacement asks the nurse, 'Why do I have to take antibiotics before getting my teeth cleaned?' Which response by the nurse is most appropriate?
- A. You are at risk of developing an infection in your heart.'
- B. Your teeth will not bleed as much if you have antibiotics.'
- C. This procedure may cause your valve to malfunction.'
- D. Antibiotics will prevent vegetative growth on your valves.'
Correct Answer: A
Rationale: Mechanical valves increase endocarditis risk; antibiotics (A) prevent heart infection during dental procedures. Bleeding (B), valve malfunction (C), and vegetative growth (D) are inaccurate.
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The client is three (3) hours post-myocardial infarction. Which data would warrant immediate intervention by the nurse?
- A. Bilateral peripheral pulses 2+.
- B. The pulse oximeter reading is 96%.
- C. The urine output is 240 mL in the last four (4) hours.
- D. Cool, clammy, diaphoretic skin.
Correct Answer: D
Rationale: Cool, clammy, diaphoretic skin (D) indicates cardiogenic shock or sympathetic response, requiring immediate intervention. Pulses (A), SpO2 (B), and urine output (C) are normal.
What is the priority problem in the client diagnosed with congestive heart failure?
- A. Fluid volume overload.
- B. Decreased cardiac output.
- C. Activity intolerance.
- D. Knowledge deficit.
Correct Answer: B
Rationale: Decreased cardiac output (B) is the primary problem in CHF, causing symptoms like fluid overload (A). Activity intolerance (C) and knowledge deficit (D) are secondary.
The nurse is administering morning medications. Which medication should be administered first?
- A. The cardiac glycoside medication, digoxin, to a client diagnosed with heart failure and who has 2+ edema of the feet.
- B. The sliding scale insulin to a client with a fasting blood glucose of 345 mg/dL who is demanding breakfast.
- C. The loop diuretic, furosemide, to a client with a 24-hour intake of 986 mL and an output of 1,400 mL.
- D. The ARB medication to a client whose blood pressure was reported by the unlicensed assistive personnel as 142/76.
Correct Answer: B
Rationale: Fasting glucose of 345 mg/dL (B) requires immediate insulin to prevent complications, especially before eating. Digoxin (A), furosemide (C), and ARB (D) are less urgent.
The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse?
- A. The 44-year-old client diagnosed with a myocardial infarction.
- B. The 65-year-old client admitted with unstable angina.
- C. The 75-year-old client scheduled for a cardiac catheterization.
- D. The 50-year-old client complaining of chest pain.
Correct Answer: C
Rationale: A client scheduled for cardiac catheterization (C) is stable, suitable for a new graduate. MI (A), unstable angina (B), and chest pain (D) require experienced care.
The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.
- A. Notify the health-care provider of a weight gain of more than one (1) pound in a week.
- B. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
- C. Instruct the client to remove the saltshaker from the dinner table.
- D. Encourage the client to monitor urine output for change in color to become dark.
- E. Discuss the importance of taking the loop diuretic furosemide at bedtime.
Correct Answer: A,B,C
Rationale: Weight gain monitoring (A) detects fluid retention, pulse counting (B) ensures digoxin safety, and removing salt (C) reduces sodium intake. Dark urine (D) is not specific, and furosemide at bedtime (E) causes nocturia, so morning dosing is preferred.