Nokea
Which assessment finding is most closely correlated with an evolving MI?
- A. Nausea
- B. Facial flushing
- C. Severe headache
- D. Coughing up pink-tinged mucus
Correct Answer: A
Rationale: Nausea is a common symptom of myocardial infarction due to vagal stimulation or pain-induced stress response.
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Which assessment finding offers the best evidence that the client can tolerate the activity involved in getting out of bed?
- A. The client's appetite has improved.
- B. The client reports a more restful sleep.
- C. The client's heart rate is stable.
- D. The client can get out of bed without assistance.
Correct Answer: C
Rationale: Stable heart rate indicates the heart can handle the increased demand of activity.
If each tablet of digoxin (Lanoxin) contains 0.25 mg, how much should the nurse administer to the client each day?
- A. 0.5 tablets
- B. 1 tablet
- C. 0.25 tablets
- D. 0.125 tablets
Correct Answer: A
Rationale: For a 0.125 mg dose with 0.25 mg tablets, administer 0.5 tablets (0.125 mg ÷ 0.25 mg = 0.5).
An older adult is admitted to the hospital with symptoms of severe dyspnea, orthopnea, diaphoresis, bubbling respirations, and cyanosis. He states that he is afraid 'something bad is about to happen.' How should the nurse position this client?
- A. Sitting upright
- B. Head lower than feet
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sitting upright reduces pulmonary congestion and improves breathing in clients with acute heart failure symptoms like dyspnea and orthopnea.
After the coronary arteriogram, the nurse must keep the client flat in bed with the affected leg in which position?
- A. Extended
- B. Flexed
- C. Abducted
- D. Adducted
Correct Answer: A
Rationale: Keeping the leg extended prevents bleeding or hematoma at the femoral artery puncture site by minimizing movement.
The nurse is caring for an elderly client who has congestive heart failure and is taking digoxin. The client should be monitored for which of the following signs of toxicity?
- A. Disorientation
- B. Weight gain
- C. Constipation
- D. Dyspnea
Correct Answer: A
Rationale: Disorientation is a neurological sign of digoxin toxicity. Weight gain, constipation, and dyspnea are not specific to digoxin toxicity.