Nokea
The nurse completes teaching the client about CAD and self-care at home. The nurse determines that teaching is effective when the client makes which statements? Select all that apply.
- A. “If I have chest pain, I should contact my physician immediately.”
- B. “I should carry my nitroglycerin in my front pants pocket so it is handy.”
- C. “If I have chest pain, I stop activity and chew a nitroglycerin tablet.”
- D. “I should always take three nitroglycerin tablets, 5 minutes apart.”
- E. “I plan to avoid being around people when they are smoking.”
- F. “I plan on walking on most days of the week for at least 30 minutes.”
Correct Answer: E;F
Rationale: Teaching is effective when the client states: E) Avoiding passive smoke to prevent vasoconstriction; F) Walking 30 minutes most days as recommended by the American Heart Association. Contacting the physician immediately is incorrect (call 911), pants pockets are not ideal for nitroglycerin storage, nitroglycerin is taken sublingually not chewed, and three tablets are not always needed.
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The client states to the clinic nurse, “I had pain in the left calf for a few days earlier in the week, but I am pain free now.” The nurse’s assessment findings include: dorsalis pedis pulses palpable, no pain upon dorsiflexion bilaterally, a few visible varicose veins in each leg, and slight swelling in only the left leg. Which is the nurse’s best action?
- A. Ask if the client has been walking more lately.
- B. Inform the HCP of the assessment findings.
- C. Ask if the client has considered taking a baby aspirin daily.
- D. Explain to the client that there are no significant findings.
Correct Answer: B
Rationale: The nurse should inform the HCP about the assessment findings. A possible DVT is taken seriously because it can lead to PE. Unilateral swelling of one leg is a classic symptom of DVT. Additional questions, aspirin advice, or dismissing findings are inappropriate without further evaluation.
The client reports pain, tenderness, and redness along the path of an arm vein where potassium chloride (KCL) is infusing IV. Which interventions should the nurse include when responding to this situation?
- A. Call the HCP immediately; administer diphenhydramine.
- B. Stop the infusion; apply a warm, moist compress to the affected area.
- C. Slow the infusion rate; teach that IV potassium is usually uncomfortable.
- D. Discontinue the potassium chloride; document the client’s allergic reaction.
Correct Answer: B
Rationale: The nurse should immediately stop the KCL infusion; signs and symptoms indicate vein inflammation, or phlebitis. After discontinuing the IV catheter, the nurse should apply a warm, moist compress and restart the IV at another location, giving the infusion at a slower rate. Other options misinterpret the situation as an allergy or fail to address the phlebitis.
The nurse is preparing the client for a thoracic aneurysm repair. Which assessment findings should prompt the nurse to conclude that a rupture may have occurred? Select all that apply.
- A. Oliguria
- B. Dyspnea
- C. Hypotension
- D. Abdominal distention
- E. Severe chest pain radiating to the back
Correct Answer: A;B;C;E
Rationale: A rupture may cause: A) Oliguria from decreased renal perfusion; B) Dyspnea from hemorrhage pressure; C) Hypotension from blood loss; E) Severe chest pain radiating to the back. Abdominal distention is associated with abdominal, not thoracic, aneurysms.
The nurse increases activity for the client with an admitting diagnosis of ACS. Which client finding best supports that the client is not tolerating the activity?
- A. Pulse rate increased by 15 beats per minute during activity
- B. BP 130/86 mm Hg before activity; 108/66 mm Hg during activity
- C. Increased dyspnea and diaphoresis relieved when sitting in a chair
- D. A mean arterial pressure (MAP) of 80 following activity
Correct Answer: B
Rationale: A drop in BP of 20 mm Hg from the baseline indicates that the client’s heart is unable to adapt to the increased energy and oxygen demands of the activity. The client is not tolerating the activity; the length of time or the intensity should be reduced. A modest pulse increase, relieved symptoms, and normal MAP are less concerning.
The client with Raynaud’s disease is seen in a vascular clinic 6 weeks after nifedipine has been prescribed. The nurse evaluates that the medication has been effective when which findings are noted?
- A. The client’s blood pressure is 110/68 mm Hg.
- B. The client states experiencing less pain and numbness.
- C. The client states that tolerance to heat is improved.
- D. The client walks without intermittent claudication
Correct Answer: B
Rationale: Raynaud’s disease is a disease in which cutaneous arteries in the extremities have recurrent episodes of vasospasm that result in pain and numbness. Nifedipine (Procardia), a calcium-channel blocker, causes vasodilation, thus reducing pain and numbness. BP changes, heat tolerance, and claudication are not primary indicators.