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Which nursing action is most appropriate to perform next?
- A. The nurse notifies the physician, requesting a hypnotic or sedative.
- B. The nurse provides a video of the surgery for the client to watch.
- C. The nurse waits until the client's spouse is present to excessive the surgery.
- D. The nurse listens as the client talks about fears concerning surgery and rehabilitation.
Correct Answer: D
Rationale: Listening to the client's fears reduces anxiety and supports emotional preparation for surgery.
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When the client asks the nurse how cholesterol acts as a cardiac risk factor, what is the best explanation?
- A. Excess fat in the blood expands the circulating blood volume.
- B. Excess fat in the blood thickens the lining of the arteries.
- C. Excess fat in the blood causes slower blood clotting.
- D. Excess fat in the blood stimulates the heart to beat faster.
Correct Answer: B
Rationale: High cholesterol contributes to atherosclerosis, where excess fat (lipids) deposits thicken and harden the arterial walls, narrowing the lumen and increasing cardiac risk.
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 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).
After providing medication instructions, the best evidence that the client knows this drug's potential side effects is when the client states it may cause which adverse effect?
- A. Muscle pain
- B. Palpitations
- C. Visual images
- D. Weight loss
Correct Answer: A
Rationale: Atorvastatin (Lipitor) can cause muscle pain (myalgia) as a common side effect, potentially progressing to rhabdomyolysis in severe cases.
The nurse provides discharge instructions for a client who has recovered after a cardiac catheterization. Which instructions should be included? Select all that apply.
- A. Take a shower rather than a tub bath until the puncture site heals.
- B. Perform leg exercises every 2 hours while awake.
- C. In the generous amount of fluids for the next 24 hours.
- D. Report worsening of pain in the leg that was catheterized.
- E. Flush the toilet twice after eliminating urine and stool in the next 24 hours.
- F. Change the dressing over the puncture site daily until it heals.
Correct Answer: A,C,D
Rationale: Showering prevents infection, generous fluids help flush contrast dye, and reporting worsening pain detects complications. Leg exercises, double flushing, and daily dressing changes are not standard.