Nokea
The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement?
- A. Instruct the client to keep a diary of activity, especially when having chest pain.
- B. Discuss the need to remove the Holter monitor during a.m. care and showering.
- C. Explain that all medications should be withheld while wearing a Holter monitor.
- D. Teach the client the importance of decreasing activity while wearing the monitor.
Correct Answer: A
Rationale: A diary (A) correlates symptoms with ECG changes on the Holter monitor. Removal (B) is incorrect, medications (C) continue, and decreasing activity (D) is unnecessary.
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The best evidence that the client is complying with the diet therapy is the report of using which type of fat for cooking?
- A. Melted margarine
- B. Clarified butter
- C. Cooking spray
- D. Liquid corn oil
Correct Answer: C
Rationale: Cooking spray is low in saturated fat and calories, aligning with a heart-healthy diet to control CAD progression.
To assess the area where the permanent pacemaker battery, the nurse knows to examine which area of the skin?
- A. Beneath the left nipple
- B. Near the brachial artery
- C. In the midsternal area
- D. Below the right clavicle
Correct Answer: D
Rationale: Pacemaker generators are typically implanted below the right clavicle.
When the client returns to the room after the percutaneous transluminal coronary angioplasty (PTCA) procedure, which assessment finding should be reported immediately to the physician?
- A. Urine output of 100 mL/hour
- B. Blood pressure of 108/68 mm Hg
- C. Dry mouth
- D. Chest pain
Correct Answer: D
Rationale: Chest pain post-PTCA may indicate re-occlusion or complications like stent thrombosis, requiring immediate reporting.
The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse?
- A. The client is keeping the affected extremity straight.
- B. The pressure dressing to the right femoral area is intact.
- C. The client is complaining of numbness in the right foot.
- D. The client's right pedal pulse is 3+ and bounding.
Correct Answer: C
Rationale: Numbness (C) suggests vascular compromise or nerve compression, requiring immediate intervention. Keeping the leg straight (A), intact dressing (B), and strong pulse (D) are expected.
A male client with angina pectoris has been having an increased number of episodes of pain recently. He is admitted for observation. During the admission interview, he tells the nurse that he has been having chest pain during the last week. Which statement by the client would be of greatest concern to the nurse?
- A. I had chest pain while I was walking in the snow on Thursday.'
- B. We went out for a big dinner to celebrate my wife's birthday, but I couldn't enjoy it because I got the pain before we got home from the restaurant.'
- C. I had chest pain yesterday while I was sitting in the living room watching television.'
- D. I felt pain all the way down my left arm after I was playing with my grandson on Monday.'
Correct Answer: C
Rationale: Chest pain at rest, such as while watching television, is concerning as it may indicate unstable angina or impending myocardial infarction, requiring urgent evaluation. Pain with activity, eating, or radiating to the arm is typical of angina but less immediately alarming.