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The client with infective endocarditis is admitted to the medical department. Which health-care provider’s order should be implemented first?
- A. Administer intravenous antibiotic.
- B. Obtain blood cultures times two (2).
- C. Schedule an echocardiogram.
- D. Encourage bedrest with bathroom privileges.
Correct Answer: B
Rationale: Blood cultures (B) are obtained first in endocarditis to identify the pathogen before antibiotics (A) obscure results. Echocardiogram (C) and bedrest (D) follow.
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The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
- A. Assist the client to go down to the smoking area for a cigarette.
- B. Transport the client to the intensive care unit (ICU) via a stretcher.
- C. Provide the client going home discharge-teaching instructions.
- D. Help position the client who is having a portable x-ray done.
Correct Answer: D
Rationale: Positioning for an x-ray (D) is within the UAP’s scope and safe. Smoking (A) is inappropriate, ICU transport (B) requires nursing judgment, and discharge teaching (C) is a nursing responsibility.
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 nurse is told in report the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?
- A. Second intercostal space, right sternal notch.
- B. Erb's point.
- C. Second intercostal space, left sternal notch.
- D. Fourth intercostal space, left sternal border.
Correct Answer: A
Rationale: Aortic stenosis murmur is best heard at the second intercostal space, right sternal notch (A), where the aortic root is closest. Erb’s point (B), left sternal notch (C), and fourth space (D) are for other murmurs.
The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first?
- A. Medicate the client with intravenous morphine.
- B. Assess the client's chest dressing and vital signs.
- C. Encourage the client to turn from side to side.
- D. Check the client's telemetry monitor.
Correct Answer: B
Rationale: Chest pain post-CABG may indicate complications. Assessing the dressing and vital signs (B) identifies bleeding or instability. Morphine (A), repositioning (C), and telemetry (D) follow.
The nurse is administering morning medications to clients on a telemetry unit. Which medication would the nurse question?
- A. Furosemide IVP to a client with a potassium level of 3.6 mEq/L.
- B. Digoxin orally to a client diagnosed with rapid atrial fibrillation.
- C. Enalapril orally to a client whose BP is 86/64 and apical pulse is 65.
- D. Morphine IVP to a client complaining of chest pain and who is diaphoretic.
Correct Answer: C
Rationale: Enalapril (C) is contraindicated with hypotension (BP 86/64), risking further BP drop. Furosemide with K+ 3.6 (A), digoxin for AF (B), and morphine for chest pain (D) are appropriate.