Nokea
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.
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To assess the area where the permanent pacemaker battery, the nurse knows to examine which area of the skin?
- A. Beneath the left nipple
- B. Near the brachial artery
- C. In the midsternal area
- D. Below the right clavicle
Correct Answer: D
Rationale: Pacemaker generators are typically implanted below the right clavicle.
The nurse is admitting a client diagnosed with coronary artery disease (CAD) and angina. Which concept is priority?
- A. Sleep, rest, activity.
- B. Comfort.
- C. Oxygenation.
- D. Perfusion.
Correct Answer: D
Rationale: CAD and angina impair perfusion (D), the priority concept, as ischemia causes symptoms. Sleep/rest (A), comfort (B), and oxygenation (C) are secondary.
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.
The nurse informs the client that the correct way to administer nitroglycerin is to place one tablet where?
- A. The nurse is the first and check
- B. At the back of the throat
- C. Under the tongue
- D. Between the teeth
Correct Answer: C
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption into the bloodstream to relieve angina.
Which assessment finding is the best indication that oxygen therapy is effective?
- A. The client's face is flushed.
- B. Capillary refill is 6 seconds.
- C. The client states, 'I'm feeling better.'
- D. The apical pulse is less bounding.
Correct Answer: C
Rationale: The client's subjective improvement in symptoms indicates effective oxygen therapy.