Nokea
While auscultating a client's bowel sounds, the nurse notes a swooshing sound to the left of the umbilical area. What would be the nurse's priority action?
- A. Percuss over the area to assess for dullness
- B. Notify the primary healthcare provider (PHCP)
- C. Gently palpate the abdomen to assess for tenderness
- D. Ask the client about recent bowel movements
Correct Answer: B
Rationale: A swooshing sound may indicate an abdominal aortic aneurysm, a life-threatening condition requiring immediate PHCP notification.
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The nurse is caring for a client with congestive heart failure (CHF). The nurse should anticipate a prescription for which medication?
- A. Enalapril
- B. Verapamil
- C. Lovastatin
- D. Gemfibrozil
Correct Answer: A
Rationale: Enalapril, an ACE inhibitor, reduces afterload and preload in CHF, improving cardiac function.
The nurse in the emergency department (ED) is triaging a client with acute chest pain. The nurse should initially
- A. insert a peripheral venous access device (VAD).
- B. obtain a 12-lead electrocardiogram (ECG).
- C. obtain a point-of-care troponin level.
- D. auscultate lung sounds.
Correct Answer: B
Rationale: A 12-lead ECG is the initial step in evaluating acute chest pain to identify myocardial ischemia or infarction.
Which of the following findings would support a diagnosis of acute myocardial infarction (AMI)? Select all that apply.
- A. Dizziness
- B. Hypotension
- C. Orthopnea
- D. Nausea
- E. Polyuria
- F. Pulsus paradoxus
Correct Answer: A,B,D
Rationale: Dizziness can result from reduced cardiac output in AMI. Hypotension may occur due to impaired cardiac function. C: Incorrect - Orthopnea is more typical of heart failure. D: Correct - Nausea is a common symptom of AMI. E: Incorrect - Polyuria is not associated with AMI. F: Incorrect - Pulsus paradoxus is linked to pericardial conditions like tamponade.
The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The nurse identifies this tracing as
- A. sinus tachycardia.
- B. supraventricular tachycardia.
- C. ventricular tachycardia.
- D. atrial flutter.
Correct Answer: C
Rationale: Ventricular tachycardia is a life-threatening arrhythmia requiring immediate intervention, characterized by wide QRS complexes on ECG.
The nurse is teaching a group of clients about varicose veins and home care management. Which of the following should the nurse include in the teaching session?
- A. When you are sitting, keep your legs lower than your heart
- B. Wear compression stockings during the day
- C. Participate in activities that have you stand for long periods
- D. Take a low-dose aspirin to prevent the development of new varicose veins
Correct Answer: B
Rationale: Compression stockings reduce venous pooling and improve circulation, a key management strategy for varicose veins.