Nokea
The nurse counts an adult's apical heart beat at 110 beats per minute. The nurse describes this as:
- A. asystole.
- B. bigeminy.
- C. tachycardia.
- D. bradycardia.
Correct Answer: C
Rationale: Tachycardia in an adult is defined as a heart rate above 100 beats per minute. Asystole is cardiac arrest with no heartbeat. Bigeminy refers to heartbeats occurring in pairs. Bradycardia is a heart rate of 60 beats or less per minute.
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If the client's pain is due to a myocardial infarction (MI), which prescribed medication would be most helpful?
- A. A nonsteroidal anti-inflammatory drug such as ibuprofen (Advil)
- B. A nonsalicylate such as acetaminophen (Tylenol)
- C. A salicylate such as aspirin
- D. An opioid such as morphine sulfate
Correct Answer: C
Rationale: Aspirin is critical in MI to inhibit platelet aggregation and prevent further thrombus formation.
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.
Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy?
- A. Keep the client in the supine position with the legs elevated.
- B. Discuss a heart transplant, which is the definitive treatment.
- C. Prepare the client for coronary artery bypass graft.
- D. Teach the client to take a calcium channel blocker in the morning.
Correct Answer: B
Rationale: Dilated cardiomyopathy may require heart transplant (B) as definitive treatment in severe cases. Supine position (A) increases preload, CABG (C) is for CAD, and calcium channel blockers (D) are not first-line.
Which modification used by the nurse is most appropriate when taking the blood pressure of a client who weighs 250 pounds?
- A. The nurse takes the blood pressure on the client's thigh.
- B. The nurse has the client lie down during the assessment.
- C. The nurse pumps the manometer up to 250 mm Hg.
- D. The nurse uses an extra-large blood pressure cuff.
Correct Answer: D
Rationale: An extra-large blood pressure cuff is appropriate for clients with larger arm circumferences, such as those who are obese, to ensure accurate readings. Using the thigh, lying down, or over-inflating the cuff does not address the need for proper cuff size.
Which nursing action is most appropriate when applying a new transdermal patient?
- A. Rotate the application site.
- B. Clean the skin with alcohol.
- C. Tape the patch to the client's chest.
- D. Take the blood pressure afterward.
Correct Answer: A
Rationale: Rotating the application site for a nitroglycerin patch prevents skin irritation and ensures consistent drug absorption.