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Which nursing action would best reduce the client's energy, the client?
- A. Administering oxygen when the client is dyspneic
- B. Staggering self-care activities over several hours
- C. Providing analgesic medications when necessary
- D. Restricting visitors to brief periods of time
Correct Answer: B
Rationale: Staggering activities conserves energy, reducing cardiac workload in recovery.
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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.
What should be included in the teaching plan for an adult who has hypertension?
- A. Reduce dietary calcium.
- B. Avoid aerobic exercise.
- C. Reduce alcohol intake.
- D. Limit fluid intake.
Correct Answer: C
Rationale: Reducing alcohol intake helps manage hypertension by lowering blood pressure. Calcium reduction, avoiding aerobic exercise, or limiting fluids are not standard recommendations.
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply.
- A. Administer morphine intramuscularly.
- B. Administer an aspirin orally.
- C. Apply oxygen via a nasal cannula.
- D. Place the client in a supine position.
- E. Administer nitroglycerin subcutaneously.
Correct Answer: B,C
Rationale: Aspirin (B) reduces clot formation, and oxygen (C) improves myocardial oxygenation. Morphine IM (A) delays absorption, supine position (D) increases preload, and nitroglycerin SC (E) is incorrect; SL is used.
The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement?
- A. Assess the apical heart rate for one (1) full minute.
- B. Notify the client's cardiac surgeon.
- C. Prepare the client for synchronized cardioversion.
- D. Determine if the client is having pain.
Correct Answer: D
Rationale: Sinus tachycardia post-CABG is often due to pain (D), which should be assessed first. Heart rate (A), notifying (B), and cardioversion (C) follow if needed.
During the postoperative period, what is the best rationale for the nurse frequently assessing the client's fluid status?
- A. Urine retention is common after a heart transplant.
- B. Urine output is an indication of perfusion to the kidneys.
- C. Hydration determines when the client needs to be transfused.
- D. Hydration indicates when fluids should be increased.
Correct Answer: B
Rationale: Urine output reflects renal perfusion, critical post-heart transplant to monitor graft function.