Nokea
The nurse is caring for an elderly client who has congestive heart failure and is taking digoxin. The client should be monitored for which of the following signs of toxicity?
- A. Disorientation
- B. Weight gain
- C. Constipation
- D. Dyspnea
Correct Answer: A
Rationale: Disorientation is a neurological sign of digoxin toxicity. Weight gain, constipation, and dyspnea are not specific to digoxin toxicity.
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When the nurse at the physician's office reviews the client's medical record, which finding is the best indication that the client's heart has been affected by sustained high blood pressure?
- A. The client has a strong S2 heart sound.
- B. The client's heart rate is 100 beats/minute when active.
- C. The client's heart is a moderate disorder
- D. The client has an irregular heart rhythm.
Correct Answer: C
Rationale: A moderate heart disorder, such as left ventricular hypertrophy, is a common consequence of sustained hypertension due to increased workload on the heart. The other options are less specific to hypertensive heart damage.
Avoiding which of the following foods is the best evidence that the client understands the nurse's dietary instructions?
- A. Pepperoni pizza
- B. Vinegar and oil salad dressing
- C. Liver and onions
- D. Lemon-pepper chicken
Correct Answer: A
Rationale: Pepperoni pizza is high in fat and sodium, which should be avoided in a low-fat, low-sodium diet post-MI.
During cardiopulmonary resuscitation (CPR), the nurse compresses the chest of an adult victim at which rate?
- A. No less than 15 compressions per minute
- B. No less than 40 compressions per minute
- C. No less than 80 compressions per minute
- D. No less than 100 compressions per minute
Correct Answer: D
Rationale: Adult CPR requires 100-120 compressions per minute to restore circulation effectively.
The nurse responds to the call light of a client who has a history of angina pectoris. He tells the nurse that he has just taken a nitroglycerin tablet sublingually for anginal pain. What action should the nurse take next?
- A. If the pain does not subside within five minutes, place a second tablet under his tongue
- B. Position him with head lower than feet
- C. Administer a narcotic as needed (PRN) for pain if he still has pain in 10 minutes
- D. Call his physician and alert the code team for possible intervention
Correct Answer: A
Rationale: If anginal pain persists five minutes after the first nitroglycerin tablet, a second tablet should be administered, with up to three doses at five-minute intervals. Positioning with head lower than feet, narcotics, or calling the physician are not the immediate next steps.
An adult who is admitted for a cardiac catheterization asks the nurse if she will be asleep during the cardiac catheterization. What is the best initial response for the nurse to make?
- A. You will be given a general anesthesia.'
- B. You will be sedated but not asleep.'
- C. The doctor will give you an anesthetic if you are having too much pain.'
- D. Why do you want to be asleep?'
Correct Answer: B
Rationale: During cardiac catheterization, clients receive sedation but remain awake, as their cooperation may be needed. General anesthesia is not used, and pain is managed with sedation, not additional anesthetics. Asking 'why' may make the client defensive and does not provide the requested information.