Nokea
Which action by a newly hired nursing assistant indicates that the nurse needs to provide more instruction to the nursing assistant on how to accurately assess the client's pulse rate?
- A. The nursing assistant places a thumb over the radial artery.
- B. The nursing assistant counts the pulse rate for 1 full minute.
- C. The nursing assistant rests the client's arm on the abdomen.
- D. The nursing assistant presses the radial artery against the bone.
Correct Answer: A
Rationale: Using the thumb to check the pulse can result in counting the assistant's own pulse, leading to inaccurate readings.
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Which interventions should the nurse discuss with the client diagnosed with coronary artery disease? Select all that apply.
- A. Instruct the client to stop smoking.
- B. Encourage the client to exercise three (3) days a week.
- C. Teach about coronary vasodilators.
- D. Prepare the client for a carotid endarterectomy.
- E. Eat foods high in monosaturated fats.
Correct Answer: A,B,C
Rationale: Stopping smoking (A), exercising (B), and vasodilators (C) reduce CAD progression. Carotid endarterectomy (D) is for stroke risk, and monounsaturated fats (E) are beneficial but not high amounts.
Which finding would strongly indicate that the cardioversion procedure has been successful?
- A. The client regains consciousness immediately.
- B. Normal sinus cardiac rhythm is restored.
- C. The physical examination of the patient is a second.
- D. The pulse pressure is approximately 40 mm Hg.
Correct Answer: B
Rationale: Restoration of normal sinus rhythm is the primary goal of cardioversion.
A male client with angina pectoris has been having an increased number of episodes of pain recently. He is admitted for observation. During the admission interview, he tells the nurse that he has been having chest pain during the last week. Which statement by the client would be of greatest concern to the nurse?
- A. I had chest pain while I was walking in the snow on Thursday.'
- B. We went out for a big dinner to celebrate my wife's birthday, but I couldn't enjoy it because I got the pain before we got home from the restaurant.'
- C. I had chest pain yesterday while I was sitting in the living room watching television.'
- D. I felt pain all the way down my left arm after I was playing with my grandson on Monday.'
Correct Answer: C
Rationale: Chest pain at rest, such as while watching television, is concerning as it may indicate unstable angina or impending myocardial infarction, requiring urgent evaluation. Pain with activity, eating, or radiating to the arm is typical of angina but less immediately alarming.
The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching?
- A. Do you have a daily bowel movement?'
- B. Do you get yearly chest x-rays (CXRs)?'
- C. Are you sexually active?'
- D. Have you had any weight change?'
Correct Answer: D
Rationale: Weight change (D) may indicate fluid retention or malnutrition, relevant to CAD management. Bowel movements (A), CXRs (B), and sexual activity (C) are less directly related.
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.