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1. How should a healthcare professional assess a patient with chest pain?
- A. Assess the severity of pain and monitor ECG
- B. Administer nitroglycerin and provide oxygen
- C. Administer aspirin and provide pain relief
- D. Monitor for nausea and administer IV fluids
Correct answer: A
Rationale: When assessing a patient with chest pain, the initial step is to assess the severity of pain and monitor the electrocardiogram (ECG) to look for signs of cardiac issues. Administering nitroglycerin and oxygen (Choice B) is a treatment option for suspected cardiac chest pain but should not precede a thorough assessment. Administering aspirin and providing pain relief (Choice C) may be indicated later, but the priority is to assess the situation first. Monitoring for nausea and administering IV fluids (Choice D) is not the initial assessment for chest pain unless there are specific indications present.
2. A nurse is teaching a client with hypertension about using a blood pressure monitor. Which of the following instructions should the nurse include?
- A. Take your blood pressure after eating
- B. Sit quietly for 5 minutes before taking your blood pressure
- C. Use a blood pressure cuff that is too small
- D. Take your blood pressure while standing
Correct answer: B
Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before taking their blood pressure. This is important because sitting quietly helps stabilize the heart rate, leading to a more accurate reading. Choice A is incorrect because taking blood pressure after eating can affect the readings. Choice C is wrong because using a blood pressure cuff that is too small can provide inaccurate readings. Choice D is also incorrect as blood pressure should be taken in a seated position for accurate results.
3. What are the key components of a focused respiratory assessment, and how do you recognize signs of respiratory distress?
- A. Inspection, Palpation, Percussion, Auscultation
- B. Palpation, Inspection, Observation, Auscultation
- C. Percussion, Inspection, Auscultation, Palpation
- D. Inspection, Percussion, Auscultation, Palpation
Correct answer: A
Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment should start with inspection (observing the breathing pattern), followed by palpation (feeling for abnormalities like crepitus), percussion (evaluating for dullness or hyperresonance), and auscultation (listening to lung sounds). This systematic approach helps to identify signs of respiratory distress, such as abnormal breath sounds, increased respiratory rate, use of accessory muscles, and cyanosis. Choices B, C, and D are incorrect because they do not follow the standard order and sequence of a focused respiratory assessment.
4. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should indicate to the nurse that the medication has been effective?
- A. Cardiac workload decreases
- B. Blood pressure increases
- C. Respiratory rate increases
- D. Temperature decreases
Correct answer: A
Rationale: The correct answer is A: Cardiac workload decreases. Digoxin helps reduce cardiac workload in clients with heart failure, improving symptoms. This reduction in workload indicates that the medication is effective. Choice B, blood pressure increases, is incorrect because digoxin typically does not directly affect blood pressure. Choice C, respiratory rate increases, is incorrect as an increased respiratory rate is not a typical indicator of digoxin effectiveness. Choice D, temperature decreases, is also incorrect as digoxin does not typically affect body temperature.
5. A nurse is providing teaching to a client who is to start taking digoxin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with food.
- B. I will contact my provider if my heart rate is below 60 beats per minute.
- C. I should take an antacid with this medication to prevent gastrointestinal upset.
- D. I will need to take this medication for 14 days.
Correct answer: B
Rationale: The client should contact their provider if their heart rate drops below 60 beats per minute, as this could indicate digoxin toxicity.
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