Nokea
The nurse assesses for which of the following in a client receiving a calcium channel blocker? Select all that apply.
- A. Crackles
- B. Bradycardia
- C. Wheezing
- D. Dyspnea
- E. Peripheral edema
Correct Answer: A,D,E
Rationale: A client receiving a calcium channel blocker should be monitored for signs of heart failure (dyspnea, weight gain, peripheral edema, abnormal lung sounds such as crackles or rales, and jugular vein distention). The physician should be notified immediately if any of these signs develop.
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A client is prescribed nitrate therapy as treatment for angina. On a follow-up visit to the clinic, the client tells the nurse that he gets dizzy and weak when he takes the medication. The nurse would identify which nursing diagnosis as most likely?
- A. Risk for Injury
- B. Risk for Infection
- C. Deficient Fluid Volume
- D. Acute Pain
Correct Answer: A
Rationale: The client is at risk for injury because of his complaints of dizziness and weakness. There is no indication that the client is experiencing an infection or has a fluid volume deficit. Complaints of pain would lead to a nursing diagnosis of Acute Pain.
A nurse is caring for a client who is prescribed transdermal nitroglycerin for angina. The nurse instructs the client to apply the patch for how long?
- A. 4 to 6 hours
- B. 6 to 8 hours
- C. 10 to 12 hours
- D. 12 to 14 hours
Correct Answer: C
Rationale: The transdermal nitroglycerin patch should be applied every day for 10 to 12 hours. If the patch is applied for a shorter time, the therapeutic dosage may not be delivered. Applying the patch for a longer time will result in the development of tolerance to the antianginal effects.
A client is receiving treatment for angina with a vasodilator. The nurse instructs the client to notify his primary health care provider about which of the following?
- A. Weight loss of 2 lb in a week
- B. Swelling of the extremities
- C. Episodes of dyspnea
- D. Heart rate increased by about 10 bpm
- E. Fainting
Correct Answer: B,C,E
Rationale: The primary health care provider should be notified if the client experiences a heart rate of 20 bpm or more above the normal rate, rapid weight gain of 5 lb or more; unusual swelling of the extremities, face, or abdomen, dyspnea; angina; severe indigestion; or fainting.
The nurse instructs a client suffering from frequent anginal attacks to keep a record of each attack. Which of the following would the nurse instruct the client to record? Select all that apply.
- A. Blood pressure
- B. Date of attack
- C. Time of attack
- D. Drug used to relieve the acute pain
- E. Dose of drug used to relieve the acute pain
Correct Answer: B,C,D,E
Rationale: Clients should keep a record of the frequency of acute anginal attacks including date of attack, time of attack, and drug and dose used to relieve the acute pain. The client should bring this record to each physician visit.
Which of the following does the nurse need to include as part of the physical assessment of a client with anginal pain? Select all that apply.
- A. Blood pressure
- B. Apical pulse
- C. Oxygen saturation
- D. Radial pulse
- E. Respiratory rate
Correct Answer: A,B,D,E
Rationale: The nurse's physical assessment of a client with angina should include blood pressure, respiratory rate, and apical and radial pulses. The physical assessment may also include weight, inspection of the extremities for edema, and auscultation of the lungs, depending on the type of heart failure.