Nokea
The nurse is caring for a client who is being evaluated for arteriosclerosis obliterans. Which complaint is the client most likely to have?
- A. Burning pain in the legs that wakens him or her at night
- B. Numbness of the feet and ankles with exercise
- C. Leg pain while walking that becomes severe enough to force him or her to stop
- D. Increasing warmth and redness of the legs when they are elevated
Correct Answer: C
Rationale: Intermittent claudication, or leg pain during walking that resolves with rest, is the hallmark symptom of arteriosclerosis obliterans due to arterial insufficiency.
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Which laboratory results would the nurse expect to be elevated if the client had a myocardial infarction (MI)?
- A. Isoenzymes and troponin
- B. Sodium and potassium
- C. Red blood cells and platelets
- D. Plasminogen and lactic acid
Correct Answer: A
Rationale: Troponin and cardiac isoenzymes (e.g., CK-MB) are specific markers of myocardial damage in MI.
The nurse is caring for a client who is receiving heparin. What drug should be readily available?
- A. Vitamin K
- B. Caffeine
- C. Calcium gluconate
- D. Protamine sulfate
Correct Answer: D
Rationale: The antidote for heparin is protamine sulfate. Vitamin K is the antidote for warfarin. Calcium gluconate is used for magnesium sulfate overdose. Caffeine is a stimulant and not an antidote.
The nurse assumes that the client understands how an echocardiogram is performed when that client tells the nurse that this examination involves imaging the heart using which of one of the following?
- A. Ultrasound waves
- B. X-ray beams
- C. Radioactive isotopes
- D. Magnetic fields
Correct Answer: A
Rationale: An echocardiogram uses ultrasound waves to create images of the heart's structure and function.
When the nurse is obtaining this client's health history, which question about pain is least helpful?
- A. How long have you been in pain?
- B. Where is your pain located?
- C. What were you doing when your pain started?
- D. What medications do you take for pain?
Correct Answer: D
Rationale: Asking about pain medications is less critical in the acute MI setting compared to timing, location, and triggers, which guide diagnosis and urgency.
If the chest pain is not relieved after taking one nitroglycerin tablet, the nurse should teach the client to take what action?
- A. Take another tablet in 5 minutes.
- B. The nurse is the energy department.
- C. Call the physician immediately.
- D. Swallow two additional tablets.
Correct Answer: A
Rationale: If angina persists after one nitroglycerin tablet, another can be taken every 5 minutes up to three doses, then seek medical help if unrelieved.