Nokea
Which assessment finding indicates a worsening condition in a client with pericarditis?
- A. Muffled heart sounds
- B. Heart rate of 80 beats per minute
- C. Blood pressure of 120/80 mmHg
- D. Mild chest discomfort
Correct Answer: A
Rationale: Muffled heart sounds suggest pericardial effusion or cardiac tamponade, indicating worsening pericarditis.
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Which should the nurse include in the plan of care for a client diagnosed with venous stasis ulcers? Select all that apply.
- A. Elevate the legs while sitting.
- B. Wear antiembolism compression stockings.
- C. Avoid injury to the lower limbs.
- D. Trim the toenails straight across.
- E. Do not apply moisturizer to the lower legs.
- F. Allow the legs to hang over the bed in a dependent position.
Correct Answer: A,B,C,D
Rationale: Leg elevation (A), compression stockings (B), injury avoidance (C), and straight toenail trimming (D) manage venous ulcers. Moisturizer (E) is beneficial, and dependent position (F) worsens edema.
When offered the pain medication, the client says to the nurse, 'If that's Motrin, I don't want it. It makes me sick to my stomach.' What is the most appropriate nursing action at this time?
- A. Tell the client that the drug is ibuprofen.
- B. Explain that the prescribed medication must be taken.
- C. Advise the client to take the drug with plenty of water.
- D. Report the information to the charge nurse.
Correct Answer: D
Rationale: Reporting the client's adverse reaction to the charge nurse ensures proper communication and potential adjustment of the medication plan.
Which instruction should the nurse provide to a client with a new implantable cardioverter-defibrillator (ICD)?
- A. Avoid strong magnetic fields.
- B. Carry heavy bags on the affected side.
- C. Resume contact sports in 2 weeks.
- D. Ignore any shocks you feel.
Correct Answer: A
Rationale: Strong magnetic fields can interfere with ICD function, so clients should avoid them.
The client is prescribed nitroglycerin for angina. Which instruction should the nurse include?
- A. Take it every day even if you feel well.
- B. Place the tablet under your tongue.
- C. Swallow the tablet with water.
- D. Apply it as a patch on your chest.
Correct Answer: B
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption to relieve angina.
Which assessment data would the nurse recognize to support the diagnosis of abdominal aortic aneurysm (AAA)?
- A. Shortness of breath.
- B. Abdominal bruit.
- C. Ripping abdominal pain.
- D. Decreased urinary output.
Correct Answer: B
Rationale: An abdominal bruit (B) is a key sign of AAA due to turbulent flow. Shortness of breath (A) is nonspecific, ripping pain (C) suggests dissection, and low urine output (D) is a complication, not diagnostic.