Nokea
The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication?
- A. The client has a BP of 110/70.
- B. The client has an apical pulse of 56.
- C. The client is complaining of a headache.
- D. The client's potassium level is 4.5 mEq/L.
Correct Answer: B
Rationale: Beta blockers slow heart rate; a pulse of 56 (B) may indicate bradycardia, warranting caution. BP 110/70 (A), headache (C), and normal potassium (D) are not contraindications.
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An adult is admitted with venous thromboembolism. What treatment should the nurse expect during the acute stage?
- A. Application of an elastic stocking
- B. Ambulation three times a day
- C. Passive range of motion exercises to the legs
- D. Use of ice packs to control pain
Correct Answer: A
Rationale: Elastic stockings promote venous return and reduce swelling in the acute stage of venous thromboembolism. Ambulation, passive exercises, or ice packs may increase risk or be less effective.
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.
Where is the correct placement for the nurse's hands before administering cardiac compressions?
- A. On the lower half of the sternum
- B. On the lower half of the xiphoid process
- C. Over the costal cartilage
- D. Directly above the manubrium
Correct Answer: A
Rationale: Hands are placed on the lower half of the sternum (center of the chest) for effective CPR compressions.
Because the client is exhibiting signs and symptoms of congestive heart failure (CHF), which position suggested by the nurse is most beneficial for the client at this time?
- A. Supine with knees slightly bent
- B. Side-lying on the right side
- C. Side-lying on the left side
- D. Semi-Fowler's position
Correct Answer: D
Rationale: Semi-Fowler's position (30-45 degrees) reduces preload and eases breathing in CHF.
The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?
- A. Sponge the client's forehead.
- B. Obtain a pulse oximetry reading.
- C. Take the client's vital signs.
- D. Assist the client to a sitting position.
Correct Answer: D
Rationale: Gasping, clamminess, and cyanosis indicate acute pulmonary edema. Sitting upright (D) improves breathing by reducing preload. Sponging (A), pulse oximetry (B), and vital signs (C) are secondary to positioning.