Nokea
While the nurse is assisting a client to ambulate as part of his cardiac rehabilitation program, the client tells the nurse he is having midsternal burning. The nurse should next:
- A. Stop and assess the client further.
- B. Measure the client's blood pressure and heart rate.
- C. Call for help and place the client in a wheelchair.
- D. Administer nitroglycerin.
Correct Answer: A
Rationale: Midsternal burning may indicate angina, so stopping and assessing further is the priority to determine the cause.
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The mother of a newborn is concerned about the number of persons with heart disease in her family. She asks the nurse when she should start her baby on a low fat, low cholesterol diet to lower the risk of heart disease, the nurse should tell her to start diet modifications:
- A. At birth.
- B. At age 2.
- C. At age 5.
- D. At age 10.
Correct Answer: B
Rationale: Diet modifications for heart disease prevention, such as low-fat, low-cholesterol diets, are generally recommended to begin at age 2, when children transition to a more varied diet.
A client is admitted to the hospital with the diagnosis of Cushing's disease. The nurse should monitor the client's laboratory studies for which associated disorder?
- A. Hypokalemia
- B. Hyperglycemia
- C. Decreased plasma cortisol levels
- D. Low white blood cell (WBC) count
Correct Answer: B
Rationale: The client with adrenocorticosteroid excess experiences hyperglycemia, hyperkalemia, elevated plasma cortisol and adrenocorticotropic hormone (ACTH) levels, and an elevated WBC count. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids on the body.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed amiodarone (Cordarone). Which of the following side effects should the nurse monitor for?
- A. Pulmonary toxicity.
- B. Hyperglycemia.
- C. Weight gain.
- D. Hair loss.
Correct Answer: A
Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect requiring regular monitoring of lung function.
A child with partial- and full-thickness burns is admitted to the pediatric unit. Which of the following should be the priority at this time?
- A. Preventing wound infection.
- B. Evaluating vital signs frequently.
- C. Maintaining fluid and electrolyte balance.
- D. Managing the child's pain.
Correct Answer: C
Rationale: Maintaining fluid and electrolyte balance is the priority in burn care to prevent hypovolemic shock due to significant fluid loss.
A client diagnosed with chronic obstructive pulmonary disease (COPD) is on home oxygen at 2 L per minute. The nurse assesses the client's respiratory rate at 22 breaths per minute. When the client reports an increase in the dyspnea, what should the nurse do initially?
- A. Determine the need to increase the oxygen.
- B. Call emergency services to come to the home.
- C. Reassure the client that there is no need to worry.
- D. Collect more information about the client's respiratory status.
Correct Answer: D
Rationale: Completing an assessment and collecting additional information regarding the client's respiratory status is the initial nursing action. The oxygen is not increased without validation of the need for further oxygen and the approval of the primary health care provider, especially because clients with COPD can retain carbon dioxide. Calling emergency services is a premature action. Reassuring the client is appropriate, but it is inappropriate to tell the client not to worry.