Nokea
Which assessment finding best supports the assumption that the client is a good treatment.
- A. Pericardial friction rub
- B. Muffled heart sounds
- C. S3 gallop
- D. Systolic murmur
Correct Answer: A
Rationale: Pericardial friction rub is characteristic of pericarditis due to inflamed pericardial layers.
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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 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.
After hearing the nurse's instructions about activity restrictions and the potentially dangerous consequences of certain activities, the client correctly states the importance for avoiding which of the following?
- A. Carrying groceries from the car
- B. Straining during a bowel movement
- C. Bathing in warm water
- D. Having sexual intercourse
Correct Answer: B
Rationale: Straining during a bowel movement increases intrathoracic pressure, raising cardiac workload and MI risk.
The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client?
- A. Explain the importance of tapering off the medication.
- B. Discuss that the medication will make the client drowsy.
- C. Instruct the client to take the medication with food.
- D. Tell the client to take the medication when the pain level is around '8.'
Correct Answer: C
Rationale: NSAIDs irritate the stomach; taking with food (C) reduces GI upset. Tapering (A) is for steroids, drowsiness (B) is not typical, and waiting for severe pain (D) delays relief.
What should be included in foot care for the client who has a peripheral vascular disorder?
- A. Soaking the feet for 20 minutes before washing them
- B. Walking barefoot only on carpeted floors
- C. Applying lotion between the toes to avoid cracking of the skin
- D. Avoiding exposure of the legs and feet to the sun
Correct Answer: D
Rationale: Avoiding sun exposure prevents skin damage in clients with compromised circulation due to peripheral vascular disease. Soaking, walking barefoot, or applying lotion between toes increase infection or injury risk.