Nokea
Which response by the nurse is most appropriate at this time?
- A. What are your concerns?
- B. Why are you so scared?
- C. Your doctor says you are doing just fine.
- D. You need to concentrate on getting well.
Correct Answer: A
Rationale: Asking about concerns encourages the client to express fears, facilitating emotional support and reducing anxiety.
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If the client understands the nurse's explanation of the heart's conduction system, which structure will the client identify as the site of the natural pacemaker? Place an X over the correct site.
- A. Sinoatrial node
- B. Atrioventricular node
- C. Bundle of His
- D. Purkinje fibers
Correct Answer: A
Rationale: The sinoatrial (SA) node is the heart's natural pacemaker, initiating electrical impulses.
The nurse assumes that the client understands how an echocardiogram is performed when that client tells the nurse that this examination involves imaging the heart using which of one of the following?
- A. Ultrasound waves
- B. X-ray beams
- C. Radioactive isotopes
- D. Magnetic fields
Correct Answer: A
Rationale: An echocardiogram uses ultrasound waves to create images of the heart's structure and function.
Which laboratory results would the nurse expect to be elevated if the client had a myocardial infarction (MI)?
- A. Isoenzymes and troponin
- B. Sodium and potassium
- C. Red blood cells and platelets
- D. Plasminogen and lactic acid
Correct Answer: A
Rationale: Troponin and cardiac isoenzymes (e.g., CK-MB) are specific markers of myocardial damage in MI.
An older adult is admitted to the hospital with symptoms of severe dyspnea, orthopnea, diaphoresis, bubbling respirations, and cyanosis. He states that he is afraid 'something bad is about to happen.' How should the nurse position this client?
- A. Sitting upright
- B. Head lower than feet
- C. Supine
- D. Prone
Correct Answer: A
Rationale: Sitting upright reduces pulmonary congestion and improves breathing in clients with acute heart failure symptoms like dyspnea and orthopnea.
A prothrombin time test should be performed regularly on persons who are taking which medication?
- A. Heparin
- B. Warfarin
- C. Phenobarbital
- D. Digoxin
Correct Answer: B
Rationale: A prothrombin time test is done to determine the effectiveness of warfarin. A partial thromboplastin time test is used for heparin. Phenobarbital and digoxin do not require regular clotting tests, though serum levels may be monitored for long-term therapy.