Nokea
Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet?
- A. I will not eat more than six (6) eggs a week.'
- B. I should bake or grill any meats I eat.'
- C. I will drink eight (8) ounces of whole milk a day.'
- D. I should not eat any type of pork products.'
Correct Answer: B
Rationale: Baking or grilling meats (B) reduces fat, aligning with a low-fat CAD diet. Six eggs (A) are excessive, whole milk (C) is high-fat, and avoiding pork (D) is overly restrictive.
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Which client would the nurse suspect of having a mitral valve prolapse?
- A. A 60-year-old female with congestive heart failure.
- B. A 23-year-old male with Marfan's syndrome.
- C. An 80-year-old male with atrial fibrillation.
- D. A 33-year-old female with Down syndrome.
Correct Answer: B
Rationale: Mitral valve prolapse is common in Marfan’s syndrome (B) due to connective tissue defects. CHF (A), atrial fibrillation (C), and Down syndrome (D) are not strongly associated.
The 45-year-old male client diagnosed with essential hypertension has decided not to take his medications. The client's BP is 178/94, indicating a perfusion issue. Which question should the nurse ask the client first?
- A. Do you have the money to buy your medication?'
- B. Does the medication give unwanted side effects?'
- C. Did you quit taking the medications because you don’t feel bad?'
- D. Can you tell me why you stopped taking the medication?'
Correct Answer: D
Rationale: Asking why the client stopped (D) is open-ended, identifying barriers like side effects (B) or asymptomatic disease (C). Financial issues (A) are secondary.
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?
- A. Administer the medication as ordered.
- B. Prepare to administer vitamin K (AquaMephyton).
- C. Hold the medication and notify the HCP.
- D. Assess the client for abnormal bleeding.
Correct Answer: A
Rationale: INR 2.7 (A) is within the therapeutic range (2–3) for mechanical valves, so administer warfarin. Vitamin K (B) reverses anticoagulation, holding (C) is unnecessary, and bleeding (D) is routine but not primary.
The client is in complete heart block. Which intervention should the nurse implement first?
- A. Prepare to insert a pacemaker.
- B. Administer atropine, an antidysrhythmic.
- C. Obtain a STAT electrocardiogram (ECG).
- D. Notify the health-care provider.
Correct Answer: B
Rationale: Complete heart block may respond to atropine (B) to increase heart rate acutely. Pacemaker (A), ECG (C), and HCP notification (D) follow if atropine fails.
The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client?
- A. Social worker.
- B. Physical therapy.
- C. Cardiac rehabilitation.
- D. Occupational therapy.
Correct Answer: C
Rationale: Cardiac rehabilitation (C) promotes recovery through exercise and education post-MI. Social work (A), physical therapy (B), and occupational therapy (D) are less specific.