Nokea
The nurse is admitting a client diagnosed with coronary artery disease (CAD) and angina. Which concept is priority?
- A. Sleep, rest, activity.
- B. Comfort.
- C. Oxygenation.
- D. Perfusion.
Correct Answer: D
Rationale: CAD and angina impair perfusion (D), the priority concept, as ischemia causes symptoms. Sleep/rest (A), comfort (B), and oxygenation (C) are secondary.
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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.
The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching?
- A. I must take all the prescribed antibiotics.'
- B. I may get a vaginal yeast infection with penicillin.'
- C. I will have no problems as long as I take my medication.'
- D. My throat culture was positive for a streptococcal infection.'
Correct Answer: C
Rationale: Assuming no problems with medication (C) ignores potential complications like recurrence, indicating a need for teaching. Completing antibiotics (A), yeast infection (B), and strep culture (D) are correct.
The nurse is functioning in the role of medication nurse during a code. Which should the nurse implement when administering amiodarone for ventricular tachycardia?
- A. Mix the medication in 100 mL of fluid and administer rapidly.
- B. Push the amiodarone directly into the nearest IV port and raise the arm.
- C. Question the physician’s order because it is not ACLS recommended.
- D. Administer via an IV pump based on mg/kg/min.
Correct Answer: D
Rationale: Amiodarone for VT is administered via IV pump (D) per ACLS (e.g., 150 mg over 10 min). Rapid infusion (A) risks hypotension, direct push (B) is incorrect, and questioning (C) is unnecessary.
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.
An adult is diagnosed with hypertension. He is prescribed chlorothiazide (Diuril) 500 mg PO. What nursing instruction is essential for him?
- A. Drink at least two quarts of liquid daily.
- B. Avoid hard cheeses.
- C. Drink orange juice or eat a banana daily.
- D. Do not take aspirin.
Correct Answer: C
Rationale: Chlorothiazide, a diuretic, can cause potassium loss. Consuming potassium-rich foods like orange juice or bananas helps prevent hypokalemia.