Nokea
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.
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Which statement is the best indication that the client understands the surgical procedure involving mitral valve replacement?
- A. My blood will be circulated through a heart-lung machine.
- B. The surgeon will enlarge my valve by inserting a stent.
- C. My blood will be opened during surgery, but my heart will not.
- D. A piece of my leg vein will be used to replace the diseased valve.
Correct Answer: A
Rationale: Mitral valve replacement requires a heart-lung machine for cardiopulmonary bypass.
When a client returns from undergoing a cardiac catheterization, it is most essential for the nurse to:
- A. check peripheral pulses.
- B. maintain NPO.
- C. apply heat to the insertion site.
- D. start range of motion exercises immediately.
Correct Answer: A
Rationale: Checking peripheral pulses post-cardiac catheterization is essential to detect complications like arterial occlusion or hematoma at the insertion site. Maintaining NPO, applying heat, or starting range of motion exercises immediately are not standard priorities.
A low-sodium diet has been ordered for an adult client. The nurse knows that the client understands his low-sodium diet when the client selects which menu?
- A. Tossed salad, carrot sticks, and steak
- B. Baked chicken, mashed potatoes, and green beans
- C. Hot dog, roll, and coleslaw
- D. Chicken noodle soup, applesauce, and cottage cheese
Correct Answer: B
Rationale: Baked chicken, mashed potatoes, and green beans are naturally low in sodium. Steak, hot dogs, and chicken noodle soup are typically high in sodium.
Please indicate with an X the best anatomic area for the nurse to auscultate mitral valve sounds.
- A. Apex of the heart
- B. Second right intercostal space
- C. Second left intercostal space
- D. Lower left sternal border
Correct Answer: A
Rationale: Mitral valve sounds are best heard at the apex (fifth intercostal space, midclavicular line).
If the literature supplied by the fast-food chain indicates that one hot apple pie contains 2 g of protein, 14 g of fat, and 31 g of carbohydrates, how many calories are contained in one hot apple pie?
- A. 250 calories
- B. 260 calories
- C. 270 calories
- D. 280 calories
Correct Answer: C
Rationale: Calories are calculated as: (2 g protein × 4 kcal/g) + (14 g fat × 9 kcal/g) + (31 g carbohydrates × 4 kcal/g) = 8 + 126 + 124 = 258 kcal, closest to 270 kcal.