Nokea
The nurse informs the client that the correct way to administer nitroglycerin is to place one tablet where?
- A. The nurse is the first and check
- B. At the back of the throat
- C. Under the tongue
- D. Between the teeth
Correct Answer: C
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption into the bloodstream to relieve angina.
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The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse?
- A. The client diagnosed with congestive heart failure who is being discharged in the morning.
- B. The client who is having frequent incontinent liquid bowel movements and vomiting.
- C. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62.
- D. The client who is complaining of chest pain on inspiration and a nonproductive cough.
Correct Answer: C
Rationale: Tachycardia, tachypnea, and hypotension (C) suggest instability, requiring experienced nursing care. Discharging CHF (A), incontinence/vomiting (B), and pleuritic pain (D) are less acute.
The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement?
- A. Instruct the UAP to stop encouraging the leg movements.
- B. Report this behavior to the charge nurse as soon as possible.
- C. Praise the UAP for encouraging the client to move the legs.
- D. Take no action concerning the UAP's behavior.
Correct Answer: C
Rationale: Leg movements (C) prevent DVT in MI patients on bedrest, so praising the UAP is appropriate. Stopping (A), reporting (B), or ignoring (D) are incorrect.
The best evidence that the client understands the nurse's instructions regarding dietary restrictions is if the client states to avoid which food?
- A. Canned soup
- B. Fresh fruit
- C. Baked chicken
- D. Whole grain bread
Correct Answer: A
Rationale: Canned soup is high in sodium, which should be avoided in a low-sodium diet for hypertension management. The other options are generally low-sodium and suitable.
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 nursing team develops a care plan and expected outcomes for the client's recovery. Which expected outcomes are most important? Select all that apply.
- A. The client will not gain weight.
- B. The client will not gain weight.
- C. The client will comply with the dietary restrictions.
- D. The client will avoid any alcoholic beverages.
- E. The client will verbalize fears and anxieties freely.
- F. The client will maintain pressure over the intravenous site.
Correct Answer: C,D,E
Rationale: Complying with dietary restrictions, avoiding alcohol, and verbalizing fears support recovery by reducing cardiac risk and addressing emotional needs.