Nokea
Which modification used by the nurse is most appropriate when taking the blood pressure of a client who weighs 250 pounds?
- A. The nurse takes the blood pressure on the client's thigh.
- B. The nurse has the client lie down during the assessment.
- C. The nurse pumps the manometer up to 250 mm Hg.
- D. The nurse uses an extra-large blood pressure cuff.
Correct Answer: D
Rationale: An extra-large blood pressure cuff is appropriate for clients with larger arm circumferences, such as those who are obese, to ensure accurate readings. Using the thigh, lying down, or over-inflating the cuff does not address the need for proper cuff size.
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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.
Which symptom would the nurse expect to observe if the client is having an allergic reaction to streptokinase (Streptase)?
- A. Urticaria
- B. Anuria
- C. Hemoptysis
- D. Dyspepsia
Correct Answer: A
Rationale: Urticaria (hives) is a common sign of an allergic reaction to streptokinase, a thrombolytic agent.
A client who has been treated for angina is discharged in stable condition. At a clinic visit, he tells the nurse he has anginal pain when he has sexual intercourse with his wife. What is the best response for the nurse to make?
- A. Do you have ambivalent feelings toward your wife?'
- B. Many persons with angina have less pain when their partner assumes the top position.'
- C. Be sure that you attempt intercourse only when you are well rested and relaxed.'
- D. You might try having a cocktail before sexual activity to help you relax.'
Correct Answer: C
Rationale: Engaging in sexual activity when well-rested and relaxed reduces cardiac demand, minimizing angina risk. Questioning feelings, suggesting positions, or recommending alcohol are less appropriate or potentially harmful.
Which client would most likely be misdiagnosed for having a myocardial infarction?
- A. A 55-year-old Caucasian male with crushing chest pain and diaphoresis.
- B. A 60-year-old Native American male with an elevated troponin level.
- C. A 40-year-old Hispanic female with a normal electrocardiogram.
- D. An 80-year-old Peruvian female with a normal CK-MB at 12 hours.
Correct Answer: C
Rationale: A 40-year-old Hispanic female with normal ECG (C) is most likely to be misdiagnosed, as women often present atypically and normal ECGs can occur in MI. Typical symptoms (A), elevated troponin (B), and normal CK-MB at 12 hours (D) are less likely to be missed.
The telemetry nurse is unable to read the telemetry monitor at the nurse’s station. Which intervention should the telemetry nurse implement first?
- A. Go to the client's room to check the client.
- B. Instruct the primary nurse to assess the client.
- C. Contact the client on the client call system.
- D. Request the nursing assistant to take the crash cart to the client's room.
Correct Answer: A
Rationale: An unreadable monitor (A) requires direct client assessment to ensure safety. Instructing another nurse (B), calling (C), or crash cart (D) are premature without assessment.