Nokea
The nurse is to obtain pedal pulses on a client following a cardiac catheterization. Which is the proper procedure?
- A. Place the fingertips against the wrist bone.
- B. Place the stethoscope over the apex of the heart.
- C. Place the fingertips against the side of the neck.
- D. Place the fingertips on top of the foot.
Correct Answer: D
Rationale: Pedal pulses are assessed by palpating the dorsalis pedis or posterior tibial arteries on the foot, checking for circulation post-catheterization.
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A client preparing for surgery.
Which of the following statements by the client BEST indicates to the nurse an emotional readiness for surgery?
- A. I know the doctor isn't telling me everything, but at this point I can't do anything about it.'
- B. I've never heard of this specialist before. Does he do much work here?'
- C. I'm glad the trapeze is on my bed so I can start working on my exercises as soon as I wake up.'
- D. Can you please check my record to be sure it says I'm diabetic?'
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) indicates feelings of fear and helplessness (2) indicates fear and lack of trust (3) correct-indicates acceptance and a readiness to participate in postoperative care (4) indicates fear that something will be missed
The nurse is teaching a client with a new diagnosis of type 2 diabetes about glipizide (Glucotrol). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication 30 minutes before breakfast.
- B. I should avoid drinking alcohol while taking this medication.
- C. I should report sweating or shakiness to my doctor.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping glipizide when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: pre-breakfast dosing maximizes efficacy, alcohol increases hypoglycemia risk, and sweating/shakiness indicate hypoglycemia.
The nurse is caring for a client with a history of stroke.
- A. Which intervention is most effective for preventing aspiration in a client with a history of stroke?
- B. Thicken liquids to a nectar consistency.
- C. Encourage small, frequent meals.
- D. Place the client in a supine position for meals.
- E. Administer an antiemetic before meals.
Correct Answer: A
Rationale: Thickening liquids to a nectar consistency slows swallowing, reducing aspiration risk in stroke patients with dysphagia. Small meals help, supine positioning increases risk, and antiemetics are irrelevant.
A 67-year-old man following a cardiac catheterization. Two hours after the procedure, the nurse checks the patient's insertion site in the antecubital space, and the patient complains that his hand is numb.
The nurse should
- A. change the position of his hand.
- B. check his grip strength in both hands.
- C. notify the physician.
- D. instruct the patient to exercise his fingers.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does the assessment answer validate what is going on? No. Determine the outcome of each answer choice. (1) assumes that numbness is related to positioning of hand, not circulatory changes (2) part of assessment, but doesn't indicate status of circulation (3) correct-absent or weak pulse or numbness could indicate problem with circulation, anticoagulants and vasodilators may be ordered (4) assumes that numbness is related to immobility of fingers, not circulatory changes
The nurse is teaching a client with a new diagnosis of type 2 diabetes about metformin (Glucophage). Which of the following instructions should the nurse include?
- A. Take the medication on an empty stomach.
- B. Report any nausea or diarrhea.
- C. Stop the medication if blood sugar is normal.
- D. Avoid regular kidney function Test s.
Correct Answer: B
Rationale: Nausea or diarrhea are common metformin side effects that may require dose adjustment, so reporting is important. Options A, C, and D are incorrect.