Nokea
The nurse has taught a client newly prescribed sublingual nitroglycerin for acute angina. Which of the following statements by the client would require follow-up?
- A. I will get a refill of my prescription every six months.
- B. I will take one tablet every 2 minutes if chest pain occurs.
- C. I will place my medication in a dark amber bottle.
- D. I must not chew on the tablet when taking it.
Correct Answer: B
Rationale: Nitroglycerin should be taken every 5 minutes (up to 3 doses) for chest pain, not every 2 minutes, to avoid overdose.
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The nurse is assessing a client's cardiac rhythm strip and notices that it is irregular without any P waves before the QRS complexes. The nurse should interpret this as
- A. sinus tachycardia.
- B. sinus bradycardia.
- C. normal sinus rhythm with premature ventricular contractions (PVC).
- D. atrial fibrillation
Correct Answer: D
Rationale: Atrial fibrillation is characterized by an irregular rhythm and absent P waves due to chaotic atrial activity.
The nurse is caring for a client who has just been diagnosed with acute pericarditis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe?
- A. isoniazid
- B. colchicine
- C. allopurinol
- D. warfarin
Correct Answer: B
Rationale: Colchicine is used to reduce inflammation in acute pericarditis, often combined with NSAIDs.
The nurse cares for a client with suspected congestive heart failure (CHF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis?
- A. Basic metabolic panel (BMP)
- B. B-type natriuretic peptide (BNP)
- C. Complete Metabolic Profile (CMP)
- D. C-Reactive Protein (CRP)
Correct Answer: B
Rationale: BNP is a specific marker for heart failure, elevated due to ventricular strain.
Which of the following assessment findings would be expected in a client with venous thromboembolism in the lower extremity? Select all that apply.
- A. Pain
- B. Swelling
- C. Paralysis
- D. Pulse deficit
- E. Dependent rubor
Correct Answer: A,B
Rationale: Pain is common due to inflammation and clot obstruction in venous thromboembolism (VTE). Swelling occurs due to venous obstruction and fluid accumulation. C: Incorrect - Paralysis is not typical in VTE; it may suggest a neurological issue. D: Incorrect - Pulse deficit is associated with arterial issues, not venous. E: Incorrect - Dependent rubor is characteristic of arterial insufficiency, not VTE.
The nurse cares for a client with the below tracing on the electrocardiogram. The client is unresponsive and without a pulse. The nurse should implement which priority treatment based on the tracing
- A. Start cardiopulmonary resuscitation (CPR)
- B. Perform immediate defibrillation
- C. Initiate intravenous (IV) access
- D. Review the client's most recent electrolyte levels
Correct Answer: B
Rationale: Pulseless ventricular fibrillation or tachycardia requires immediate defibrillation to restore rhythm.