Nokea
When the nurse informs the client about the use of the PCA pump, which instruction is most important to include?
- A. Press the button only when pain is severe.
- B. Only the client should press the PCA button.
- C. Wait 30 minutes between doses.
- D. Record the number of doses used.
Correct Answer: B
Rationale: Only the client should press the PCA button to prevent overdose and ensure pain relief is patient-controlled.
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The nurse counts an adult's apical heart beat at 110 beats per minute. The nurse describes this as:
- A. asystole.
- B. bigeminy.
- C. tachycardia.
- D. bradycardia.
Correct Answer: C
Rationale: Tachycardia in an adult is defined as a heart rate above 100 beats per minute. Asystole is cardiac arrest with no heartbeat. Bigeminy refers to heartbeats occurring in pairs. Bradycardia is a heart rate of 60 beats or less per minute.
When obtaining a health history from this client, which finding strongly suggests that the client is hypertensive? Select all that apply.
- A. Unexplained nosebleeds
- B. Difficulty sleeping at night
- C. Waking to urinate at night
- D. Occasional heart palpitations
- E. Dizziness
- F. Pale skin color
Correct Answer: A,C,E
Rationale: Unexplained nosebleeds, waking to urinate at night (nocturia), and dizziness are symptoms associated with hypertension due to increased vascular pressure, kidney effects, and cerebral hypoperfusion, respectively.
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 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.
Before administering the digoxin (Lanoxin) to the client, what nursing assessment is essential?
- A. The client's heart rate
- B. The client's blood pressure
- C. The client's heart sounds
- D. The client's breath sounds
Correct Answer: A
Rationale: Check heart rate; withhold digoxin if <60 bpm to prevent toxicity.