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The nurse responds to the call light of a client who has a history of angina pectoris. He tells the nurse that he has just taken a nitroglycerin tablet sublingually for anginal pain. What action should the nurse take next?
- A. If the pain does not subside within five minutes, place a second tablet under his tongue
- B. Position him with head lower than feet
- C. Administer a narcotic as needed (PRN) for pain if he still has pain in 10 minutes
- D. Call his physician and alert the code team for possible intervention
Correct Answer: A
Rationale: If anginal pain persists five minutes after the first nitroglycerin tablet, a second tablet should be administered, with up to three doses at five-minute intervals. Positioning with head lower than feet, narcotics, or calling the physician are not the immediate next steps.
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A low-sodium diet has been ordered for an adult client. The nurse knows that the client understands his low-sodium diet when the client selects which menu?
- A. Tossed salad, carrot sticks, and steak
- B. Baked chicken, mashed potatoes, and green beans
- C. Hot dog, roll, and coleslaw
- D. Chicken noodle soup, applesauce, and cottage cheese
Correct Answer: B
Rationale: Baked chicken, mashed potatoes, and green beans are naturally low in sodium. Steak, hot dogs, and chicken noodle soup are typically high in sodium.
Which information about the client's use of a patient-controlled analgesia (PCA) pump is most important to communicate to the staff on the next shift?
- A. Name of the client's physician
- B. Purpose for using the pump
- C. Number of doses administered
- D. The client's need for further teaching
Correct Answer: C
Rationale: The number of doses administered is critical for monitoring pain control and preventing overdose.
An adult male is being evaluated for possible dysrhythmia and is to be placed on a Holter monitor. What instructions should the nurse give him to ensure that this test provides a comprehensive picture of his cardiac status?
- A. Remove the electrodes intermittently for hygiene measures.
- B. Exercise frequently while the monitor is in place.
- C. Keep a diary of all your activities while being monitored.
- D. Refrain from activities that precipitate symptoms.
Correct Answer: C
Rationale: Keeping a diary of activities correlates symptoms or dysrhythmias with specific triggers, providing a comprehensive picture for diagnosis.
Which assessment finding should signal the nurse to withhold applying the client's nitroglycerin patch and notify the physician?
- A. The pressure of 99.8°F (37.6°C)
- B. Respiratory rate of 24 breaths/minute at rest
- C. Apical heart rate of 90 beats/minute
- D. Blood pressure of 94/62 mm Hg
Correct Answer: D
Rationale: A blood pressure of 94/62 mm Hg indicates hypotension, a contraindication for nitroglycerin, which can further lower blood pressure.
A low-sodium, low-cholesterol, weight-reducing diet is prescribed for an adult with heart disease. The nurse knows that he understands his diet when he chooses which of the following meals?
- A. Baked skinless chicken and mashed potatoes
- B. Stir-fried Chinese vegetables and rice
- C. Tuna fish salad with celery sticks
- D. Grilled lean steak Ascertainly grilled lean steak with carrots
Correct Answer: A
Rationale: Baked skinless chicken and mashed potatoes are low in sodium and cholesterol, making them suitable for a heart-healthy diet. Stir-fried vegetables may contain high sodium sauces, tuna salad may include high-sodium dressings, and grilled steak is higher in cholesterol.