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 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.
To provide adequate care for the client with worsening left-sided heart failure, the intensive care unit (ICU) nurse should be a full of the following on a daily basis?
- A. Pupil response
- B. Peripheral edema
- C. Appetite
- D. Weight
Correct Answer: B,D
Rationale: Peripheral edema and weight are key indicators of fluid status in heart failure.
Which action by a newly hired nursing assistant indicates that the nurse needs to provide more instruction to the nursing assistant on how to accurately assess the client's pulse rate?
- A. The nursing assistant places a thumb over the radial artery.
- B. The nursing assistant counts the pulse rate for 1 full minute.
- C. The nursing assistant rests the client's arm on the abdomen.
- D. The nursing assistant presses the radial artery against the bone.
Correct Answer: A
Rationale: Using the thumb to check the pulse can result in counting the assistant's own pulse, leading to inaccurate readings.
When providing dietary instructions for this client, which healthful alternative should the nurse recommend?
- A. Wheat toast for white bread
- B. Margarine for butter
- C. Cereal for eggs
- D. Ham for sausage
Correct Answer: C
Rationale: Cereal is a low-cholesterol, heart-healthy alternative to eggs, which are high in cholesterol. Wheat toast and margarine still contain some fats, and ham is high in sodium and fat.
Before the cardiac catheterization and coronary arteriogram, it is essential for the nurse will be taken about any allergy to iodine or which other substance?
- A. Penicillin
- B. Morphine
- C. Shellfish
- D. Eggs
Correct Answer: C
Rationale: Shellfish allergies often indicate a risk of iodine sensitivity, which is critical since contrast dye used in arteriograms contains iodine.