Nokea
Which assessment finding should signal the nurse to withhold applying the client's nitroglycerin patch and notify the physician?
- A. The pressure of 99.8°F (37.6°C)
- B. Respiratory rate of 24 breaths/minute at rest
- C. Apical heart rate of 90 beats/minute
- D. Blood pressure of 94/62 mm Hg
Correct Answer: D
Rationale: A blood pressure of 94/62 mm Hg indicates hypotension, a contraindication for nitroglycerin, which can further lower blood pressure.
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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.
What is the best explanation for the drug therapy in this situation?
- A. Aspirin tends to relieve chest pain.
- B. Aspirin tends to prevent blood clots.
- C. Aspirin tends to lower the blood pressure.
- D. Aspirin tendsmedi tends to dilate the coronary arteries.
Correct Answer: B
Rationale: Aspirin's antiplatelet effect prevents thrombus formation at the PTCA site, reducing the risk of re-occlusion.
If the chest pain is not relieved after taking one nitroglycerin tablet, the nurse should teach the client to take what action?
- A. Take another tablet in 5 minutes.
- B. The nurse is the energy department.
- C. Call the physician immediately.
- D. Swallow two additional tablets.
Correct Answer: A
Rationale: If angina persists after one nitroglycerin tablet, another can be taken every 5 minutes up to three doses, then seek medical help if unrelieved.
The nurse understands that the client's hesitation in going to the hospital is an example of which coping mechanism?
- A. Regression
- B. Projection
- C. Denial
- D. Undoing
Correct Answer: C
Rationale: Denial involves minimizing or ignoring symptoms, such as attributing chest pain to muscle strain, delaying medical care.
An adult client is admitted to the hospital with peripheral vascular disease of the lower extremities. He has several ischemic ulcers on each ankle and lower leg area. Other parts of his skin are shiny and taut with loss of hair. A primary nursing goal for this client should be to do which of the following?
- A. Increase activity tolerance
- B. Relieve anxiety
- C. Protect from injury
- D. Help build a positive body image
Correct Answer: C
Rationale: Protecting from injury is critical for a client with peripheral vascular disease and ischemic ulcers to prevent infection and further tissue damage. Other goals are secondary.