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The telemetry nurse is unable to read the telemetry monitor at the nurse’s station. Which intervention should the telemetry nurse implement first?
- A. Go to the client's room to check the client.
- B. Instruct the primary nurse to assess the client.
- C. Contact the client on the client call system.
- D. Request the nursing assistant to take the crash cart to the client's room.
Correct Answer: A
Rationale: An unreadable monitor (A) requires direct client assessment to ensure safety. Instructing another nurse (B), calling (C), or crash cart (D) are premature without assessment.
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A client who has been treated for angina is discharged in stable condition. At a clinic visit, he tells the nurse he has anginal pain when he has sexual intercourse with his wife. What is the best response for the nurse to make?
- A. Do you have ambivalent feelings toward your wife?'
- B. Many persons with angina have less pain when their partner assumes the top position.'
- C. Be sure that you attempt intercourse only when you are well rested and relaxed.'
- D. You might try having a cocktail before sexual activity to help you relax.'
Correct Answer: C
Rationale: Engaging in sexual activity when well-rested and relaxed reduces cardiac demand, minimizing angina risk. Questioning feelings, suggesting positions, or recommending alcohol are less appropriate or potentially harmful.
The nurse is teaching a class on valve replacements. Which statement identifies a disadvantage of having a biological tissue valve replacement?
- A. The client must take lifetime anticoagulant therapy.
- B. The client’s infections are easier to treat.
- C. There is a low incidence of thromboembolism.
- D. The valve has to be replaced frequently.
Correct Answer: D
Rationale: Biological valves (D) have limited durability, often requiring replacement. Anticoagulation (A) is for mechanical valves, infections (B) are not easier, and thromboembolism (C) is lower but not a disadvantage.
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply.
- A. Administer morphine intramuscularly.
- B. Administer an aspirin orally.
- C. Apply oxygen via a nasal cannula.
- D. Place the client in a supine position.
- E. Administer nitroglycerin subcutaneously.
Correct Answer: B,C
Rationale: Aspirin (B) reduces clot formation, and oxygen (C) improves myocardial oxygenation. Morphine IM (A) delays absorption, supine position (D) increases preload, and nitroglycerin SC (E) is incorrect; SL is used.
Which assessment finding documented by the nurse provides the best evidence that the client has a bacterial infection?
- A. Chest pain
- B. Dry cough
- C. Fever
- D. Dyspnea
Correct Answer: C
Rationale: Fever is a hallmark of bacterial infection, such as in endocarditis.
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.