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The nurse has instructed a client who is scheduled to have a carotid ultrasound. Which of the following statements by the client would require follow up?
- A. I plan to eat a light meal before the ultrasound.
- B. I will remove any jewelry or metal objects from my neck before the procedure.
- C. I understand that the ultrasound will use sound waves to create images of my carotid arteries.
- D. I should fast for at least 8 hours before the ultrasound.
Correct Answer: D
Rationale: Carotid ultrasound does not require fasting, so this statement requires correction.
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The nurse is teaching a client who is scheduled for an exercise electrocardiography (ECG) test. Which of the following statements by the client would require follow-up?
- A. I should wear loose, comfortable clothing with non-slip athletic footwear.
- B. I may have a small cup of coffee before the exam.
- C. I will have my blood pressure, heart rate, and rhythm obtained before, during, and after the stress test.
- D. I should not do any strenuous activity before the test.
Correct Answer: B
Rationale: Caffeine can affect heart rate and ECG results, so coffee should be avoided before an exercise ECG test.
Which action should the nurse prepare to take for a client experiencing a myocardial infarction? Select all that apply.
- A. Start a peripheral vascular access device (VAD)
- B. Obtain a prescription for albuterol via nebulizer
- C. Obtain a prescription for chewable aspirin
- D. Obtain a prescription for nitroglycerin
- E. Obtain an order for a chest radiograph (x-ray)
- F. Establish continuous cardiac monitoring
Correct Answer: A,C,D,F
Rationale: IV access is needed for medications. B: Incorrect - Albuterol is for respiratory issues, not MI. C: Correct - Aspirin reduces clot formation. D: Correct - Nitroglycerin relieves chest pain and reduces preload. E: Incorrect - Chest X-ray is not a priority in acute MI. F: Correct - Cardiac monitoring detects arrhythmias.
Which of the following findings would the nurse expect to observe in a client who has developed cardiac tamponade? Select all that apply.
- A. Unilateral crackles
- B. Systolic murmur
- C. Bradycardia
- D. Jugular venous distention
- E. Hypotension
Correct Answer: D,E
Rationale: Unilateral crackles suggest pulmonary issues, not tamponade. B: Incorrect - Systolic murmur is not specific to tamponade. C: Incorrect - Tachycardia, not bradycardia, is typical in tamponade due to compensatory mechanisms. D: Correct - Jugular venous distention occurs due to increased venous pressure. E: Correct - Hypotension results from reduced cardiac output in tamponade.
While auscultating a client's bowel sounds, the nurse notes a swooshing sound to the left of the umbilical area. What would be the nurse's priority action?
- A. Percuss over the area to assess for dullness
- B. Notify the primary healthcare provider (PHCP)
- C. Gently palpate the abdomen to assess for tenderness
- D. Ask the client about recent bowel movements
Correct Answer: B
Rationale: A swooshing sound may indicate an abdominal aortic aneurysm, a life-threatening condition requiring immediate PHCP notification.
The home health nurse is caring for a client who experienced a myocardial infarction two weeks ago. Which of the following client statement requires immediate follow-up?
- A. I am having difficulty coping with the stress at work.
- B. I am unsure if I want to continue with cardiac rehabilitation.
- C. I have not been taking my prescribed clopidogrel because I cannot afford it.
- D. I started using nicotine patches to help me quit smoking.
Correct Answer: C
Rationale: Clopidogrel is critical for preventing stent thrombosis post-MI. Non-adherence requires urgent follow-up.