Nokea
Which side effects are most closely associated with the use of nitroglycerin tablets? Select all that apply.
- A. Headache
- B. Backache
- C. Headache
- D. Jaundice
- E. Dizziness
- F. Pallor
Correct Answer: A,E
Rationale: Nitroglycerin causes vasodilation, leading to headache (due to cerebral vasodilation) and dizziness (due to hypotension). Backache, jaundice, and pallor are not typical.
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When auscultating the client's heart and breath sounds during a routine shift assessment, which action by the nurse is most appropriate?
- A. Asking the client to hold the breath
- B. Using the bell of the stethoscope
- C. Positioning the client flat in bed
- D. Locating the xiphoid process
Correct Answer: B
Rationale: The bell of the stethoscope is best for low-pitched heart sounds in pericarditis.
When the nurse at the physician's office reviews the client's medical record, which finding is the best indication that the client's heart has been affected by sustained high blood pressure?
- A. The client has a strong S2 heart sound.
- B. The client's heart rate is 100 beats/minute when active.
- C. The client's heart is a moderate disorder
- D. The client has an irregular heart rhythm.
Correct Answer: C
Rationale: A moderate heart disorder, such as left ventricular hypertrophy, is a common consequence of sustained hypertension due to increased workload on the heart. The other options are less specific to hypertensive heart damage.
As part of the discharge instructions, the nurse correctly instructs the client that which symptom is a sign of artificial pacemaker malfunction?
- A. Tingling in the chest area
- B. Dizziness during activity
- C. Pain radiating to the arm
- D. Tenderness beneath the skin
Correct Answer: B
Rationale: Dizziness during activity may indicate pacemaker failure to maintain adequate heart rate.
Which information about the client's use of a patient-controlled analgesia (PCA) pump is most important to communicate to the staff on the next shift?
- A. Name of the client's physician
- B. Purpose for using the pump
- C. Number of doses administered
- D. The client's need for further teaching
Correct Answer: C
Rationale: The number of doses administered is critical for monitoring pain control and preventing overdose.
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.