Nokea
The nurse knows that the client understands how to determine when the nitroglycerin tablets need replacing when the client makes which statement?
- A. The tablets will be discovered.
- B. The tablets will be discolored.
- C. They won't tingle in my mouth.
- D. They will disintegrate when I touch them.
Correct Answer: C
Rationale: Fresh nitroglycerin tablets cause a tingling sensation under the tongue; loss of this sensation indicates loss of potency.
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What should be included in foot care for the client who has a peripheral vascular disorder?
- A. Soaking the feet for 20 minutes before washing them
- B. Walking barefoot only on carpeted floors
- C. Applying lotion between the toes to avoid cracking of the skin
- D. Avoiding exposure of the legs and feet to the sun
Correct Answer: D
Rationale: Avoiding sun exposure prevents skin damage in clients with compromised circulation due to peripheral vascular disease. Soaking, walking barefoot, or applying lotion between toes increase infection or injury risk.
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.
If the client's severe chest pain is typical of other people who experience myocardial infarction (MI), the client is most likely to tell the nurse that the discomfort radiates to which area?
- A. Flank
- B. Groin
- C. Abdomen
- D. Shoulder
Correct Answer: D
Rationale: MI pain typically radiates to the shoulder, arm, or jaw due to referred pain from cardiac ischemia.
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.
After the client has been successfully resuscitated by the nurse, which body position is most correct while awaiting transfer to the emergency department?
- A. Supine with the head elevated
- B. On the side upper knee flexed
- C. Prone with the head lowered
- D. Flat with the knees extended
Correct Answer: D
Rationale: Flat with knees extended ensures airway patency and circulation stability post-resuscitation.