Nokea
Which assessment finding is the best indication that oxygen therapy is effective?
- A. The client's face is flushed.
- B. Capillary refill is 6 seconds.
- C. The client states, 'I'm feeling better.'
- D. The apical pulse is less bounding.
Correct Answer: C
Rationale: The client's subjective improvement in symptoms indicates effective oxygen therapy.
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Because the client is exhibiting signs and symptoms of congestive heart failure (CHF), which position suggested by the nurse is most beneficial for the client at this time?
- A. Supine with knees slightly bent
- B. Side-lying on the right side
- C. Side-lying on the left side
- D. Semi-Fowler's position
Correct Answer: D
Rationale: Semi-Fowler's position (30-45 degrees) reduces preload and eases breathing in CHF.
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.
The nurse knows that the client understands the physician's explanation of the PTCA procedure when the client makes which statement?
- A. A balloon-tipped catheter will be inserted into my coronary artery.
- B. A Teflon graft will be used to replace an area of my artery.
- C. A section of my leg vein will be grafted around a narrowed coronary artery.
- D. A battery-operated pacemaker will be implanted to maintain my heart rate.
Correct Answer: A
Rationale: PTCA involves inflating a balloon-tipped catheter to open a narrowed coronary artery, improving blood flow.
An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?
- A. Blood clots
- B. Ecchymotic areas
- C. Jaundice
- D. Infection
Correct Answer: B
Rationale: The normal clotting time is 9 to 12 minutes. A prolonged clotting time suggests a bleeding tendency, so the client should be observed for signs of bleeding, such as ecchymotic areas. Blood clots would occur with a shorter clotting time. Jaundice is related to liver damage or red blood cell breakdown. Infection is associated with low white blood cell counts.
The nurse knows that the client understands how to determine when the nitroglycerin tablets need replacing when the client makes which statement?
- A. The tablets will be discovered.
- B. The tablets will be discolored.
- C. They won't tingle in my mouth.
- D. They will disintegrate when I touch them.
Correct Answer: C
Rationale: Fresh nitroglycerin tablets cause a tingling sensation under the tongue; loss of this sensation indicates loss of potency.