Nokea
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.
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The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement?
- A. Restrict the client's fluids as ordered.
- B. Keep the client in the supine position.
- C. Maintain oxygen saturation at 90%.
- D. Monitor the total parenteral nutrition.
Correct Answer: A
Rationale: Fluid restriction (A) prevents overload post-mitral valve surgery. Supine position (B) increases preload, SpO2 90% (C) is too low, and TPN (D) is not routine.
The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client?
- A. Explain the importance of tapering off the medication.
- B. Discuss that the medication will make the client drowsy.
- C. Instruct the client to take the medication with food.
- D. Tell the client to take the medication when the pain level is around '8.'
Correct Answer: C
Rationale: NSAIDs irritate the stomach; taking with food (C) reduces GI upset. Tapering (A) is for steroids, drowsiness (B) is not typical, and waiting for severe pain (D) delays relief.
According to the nurse, when is the correct time to note the diastolic blood pressure reading?
- A. When the loud knocking sounds become muffled
- B. When the last loud knocking sound is heard
- C. When the swishing sound is a second
- D. When the swishing sound becomes faint
Correct Answer: B
Rationale: The diastolic blood pressure is recorded at the point when the last loud knocking sound (Korotkoff phase V) is heard, indicating the pressure at which blood flow is fully restored.
The nurse enters the client's room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. The concept of perfusion is identified by the nurse. Which should the nurse implement first?
- A. Notify the health care provider.
- B. Call a rapid response team (RRT).
- C. Determine the telemetry monitor reading.
- D. Push the Code Blue button.
Correct Answer: D
Rationale: No pulse/respirations indicate cardiac arrest; pushing the Code Blue button (D) initiates the code team. Notifying HCP (A), RRT (B), or checking telemetry (C) delay resuscitation.
The nurse identifies the concept of perfusion for a client diagnosed with congestive heart failure. Which assessment data support this concept?
- A. The client has a large abdomen and a positive tympanic wave.
- B. The client has paroxysmal nocturnal dyspnea.
- C. The client has 2+ glucose in the urine.
- D. The client has a comorbid condition of myocardial infarction.
Correct Answer: B
Rationale: PND (B) indicates fluid overload in CHF, supporting impaired perfusion. Large abdomen (A) suggests ascites, glucosuria (C) is diabetes-related, and MI (D) is a cause, not a symptom.