Nokea
The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?
- A. Sponge the client's forehead.
- B. Obtain a pulse oximetry reading.
- C. Take the client's vital signs.
- D. Assist the client to a sitting position.
Correct Answer: D
Rationale: Gasping, clamminess, and cyanosis indicate acute pulmonary edema. Sitting upright (D) improves breathing by reducing preload. Sponging (A), pulse oximetry (B), and vital signs (C) are secondary to positioning.
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When the nurse is about to administer digoxin to a client, the client says, 'I think I need to see the eye doctor. Things seem to look kind of green today.' The nurse takes his vital signs, which are blood pressure = 150/94, pulse = 60 bpm, and respirations = 28. What is the most appropriate initial action for the nurse to take?
- A. Administer the medication and record the findings on his chart
- B. Withhold the digoxin and report to the charge nurse
- C. Request an appointment with the ophthalmologist
- D. Reassure the client that he is having a normal reaction to his medication
Correct Answer: B
Rationale: Visual disturbances, such as seeing a green or yellow halo, are signs of digoxin toxicity. The nurse should withhold the medication and report to the charge nurse for further evaluation.
The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching?
- A. Be sure to allow for uninterrupted rest and sleep.
- B. Refer the client to outpatient occupational therapy.
- C. Maintain oxygen via nasal cannula at two (2) L/min.
- D. Discuss upcoming valve replacement surgery.
Correct Answer: A
Rationale: Rest and sleep (A) reduce cardiac demand in pericarditis. Occupational therapy (B), oxygen (C), and valve surgery (D) are not indicated.
Using the following cardiac structures, trace the normal stress in which blood circulates on the left side of the heart. Use all the options.
- A. Aorta
- B. Left ventricle
- C. Pulmonary veins
- D. Left atrium
- E. Mitral valve (correct sequence: 3, 4, 5, 2, 1)
Correct Answer: D
Rationale: Blood flows: pulmonary veins → left atrium → mitral valve → left ventricle → aorta.
The nurse is teaching an adult who has angina about taking nitroglycerin. The nurse tells him he will know the nitroglycerin is effective when:
- A. he experiences tingling under the tongue.
- B. his pulse rate increases.
- C. his pain subsides.
- D. his activity tolerance increases.
Correct Answer: C
Rationale: The effectiveness of nitroglycerin is indicated by the relief of anginal pain. Tingling, increased pulse rate, or improved activity tolerance are not direct indicators of its effectiveness.
The nurse is transcribing the doctor’s orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement?
- A. Discuss the order with the health-care provider.
- B. Take the client’s apical pulse rate before administering.
- C. Check the client’s potassium level before giving the medication.
- D. Determine if a digoxin level has been drawn.
Correct Answer: A
Rationale: Lanoxin (digoxin) 2.5 mg (A) exceeds the safe dose (0.125–0.25 mg daily), requiring HCP clarification. Pulse (B), potassium (C), and digoxin level (D) are routine but secondary to dose error.