Nokea
When the nurse is about to administer digoxin to a client, the client says, 'I think I need to see the eye doctor. Things seem to look kind of green today.' The nurse takes his vital signs, which are blood pressure = 150/94, pulse = 60 bpm, and respirations = 28. What is the most appropriate initial action for the nurse to take?
- A. Administer the medication and record the findings on his chart
- B. Withhold the digoxin and report to the charge nurse
- C. Request an appointment with the ophthalmologist
- D. Reassure the client that he is having a normal reaction to his medication
Correct Answer: B
Rationale: Visual disturbances, such as seeing a green or yellow halo, are signs of digoxin toxicity. The nurse should withhold the medication and report to the charge nurse for further evaluation.
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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.
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.
Which symptom would the nurse expect to observe if the client is having an allergic reaction to streptokinase (Streptase)?
- A. Urticaria
- B. Anuria
- C. Hemoptysis
- D. Dyspepsia
Correct Answer: A
Rationale: Urticaria (hives) is a common sign of an allergic reaction to streptokinase, a thrombolytic agent.
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.
Before the cardiac catheterization and coronary arteriogram, it is essential for the nurse will be taken about any allergy to iodine or which other substance?
- A. Penicillin
- B. Morphine
- C. Shellfish
- D. Eggs
Correct Answer: C
Rationale: Shellfish allergies often indicate a risk of iodine sensitivity, which is critical since contrast dye used in arteriograms contains iodine.