Nokea
The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching?
- A. I should keep the tablets in the dark-colored bottle they came in.'
- B. If the tablets do not burn under my tongue, they are not effective.'
- C. I should keep the bottle with me in my pocket at all times.'
- D. If my chest pain is not gone with one tablet, I will go to the ER.'
Correct Answer: B
Rationale: Burning under the tongue (B) is not a reliable indicator of nitroglycerin effectiveness; potency is maintained in a dark bottle (A, C). Persistent pain requires up to 3 doses, not immediate ER (D).
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Which nursing action can best help reduce the client's anxiety in this situation?
- A. Teach the client how coronary artery disease (CAD) is usually treated.
- B. Listen to the client's feelings about this condition.
- C. Explain that the procedure has been very helpful for other clients.
- D. Avoid discussing the heart catheterization until the client has relaxed.
Correct Answer: B
Rationale: Listening to the client's feelings validates their emotions and reduces anxiety by fostering trust and open communication.
What should be included in foot care for the client who has a peripheral vascular disorder?
- A. Soaking the feet for 20 minutes before washing them
- B. Walking barefoot only on carpeted floors
- C. Applying lotion between the toes to avoid cracking of the skin
- D. Avoiding exposure of the legs and feet to the sun
Correct Answer: D
Rationale: Avoiding sun exposure prevents skin damage in clients with compromised circulation due to peripheral vascular disease. Soaking, walking barefoot, or applying lotion between toes increase infection or injury risk.
The nursing team develops a care plan and expected outcomes for the client's recovery. Which expected outcomes are most important? Select all that apply.
- A. The client will not gain weight.
- B. The client will not gain weight.
- C. The client will comply with the dietary restrictions.
- D. The client will avoid any alcoholic beverages.
- E. The client will verbalize fears and anxieties freely.
- F. The client will maintain pressure over the intravenous site.
Correct Answer: C,D,E
Rationale: Complying with dietary restrictions, avoiding alcohol, and verbalizing fears support recovery by reducing cardiac risk and addressing emotional needs.
Which action by a newly hired nursing assistant indicates that the nurse needs to provide more instruction to the nursing assistant on how to accurately assess the client's pulse rate?
- A. The nursing assistant places a thumb over the radial artery.
- B. The nursing assistant counts the pulse rate for 1 full minute.
- C. The nursing assistant rests the client's arm on the abdomen.
- D. The nursing assistant presses the radial artery against the bone.
Correct Answer: A
Rationale: Using the thumb to check the pulse can result in counting the assistant's own pulse, leading to inaccurate readings.
The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement?
- A. Instruct the UAP to stop encouraging the leg movements.
- B. Report this behavior to the charge nurse as soon as possible.
- C. Praise the UAP for encouraging the client to move the legs.
- D. Take no action concerning the UAP's behavior.
Correct Answer: C
Rationale: Leg movements (C) prevent DVT in MI patients on bedrest, so praising the UAP is appropriate. Stopping (A), reporting (B), or ignoring (D) are incorrect.