The nurse, who is caring for a client diagnosed with coronary artery disease, prioritizes the problem of impaired tissue perfusion in the plan of care. Which outcome would be most appropriate? The client will:
have a urinary output of greater than 30 mL per hour for 24 hours.
discuss which lifestyle modifications will be necessary to maintain health.
express no complaints of chest discomfort or shortness of breath.
have clear breath sounds bilaterally upon auscultation.
The Correct Answer is C
Choice A reason: Having a urinary output of greater than 30 mL per hour for 24 hours is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of fluid volume excess or renal impairment, which are not the case for this client.
Choice B reason: Discussing which lifestyle modifications will be necessary to maintain health is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of knowledge deficit or risk for recurrence, which are not the priority for this client.
Choice C reason: Expressing no complaints of chest discomfort or shortness of breath is the most appropriate outcome for the problem of impaired tissue perfusion. This outcome indicates that the client's cardiac output and oxygen delivery are adequate and that the interventions are effective.
Choice D reason: Having clear breath sounds bilaterally upon auscultation is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of impaired gas exchange or pulmonary congestion, which are not the case for this client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Decreasing the incidence of tachycardia is not the main therapeutic effect of atenolol for coronary artery disease. Atenolol is a beta-blocker that lowers the heart rate, but this is not the primary goal of therapy for coronary artery disease. Coronary artery disease is caused by atherosclerosis, which is the buildup of plaque in the arteries that supply the heart. This reduces the blood flow and oxygen to the heart muscle and causes angina, or chest pain.
Choice B reason: Dilating the coronary arteries is not the therapeutic effect of atenolol for coronary artery disease. Atenolol does not directly affect the diameter of the coronary arteries. It works by blocking the beta receptors in the heart and reducing the response to adrenaline and other stress hormones. This lowers the blood pressure and the oxygen demand of the heart.
Choice C reason: This is the correct answer. Decreasing cardiac workload is the therapeutic effect of atenolol for coronary artery disease. Atenolol reduces the contractility and the excitability of the heart muscle, which lowers the force and the frequency of the heartbeats. This decreases the amount of work that the heart has to do and the amount of oxygen that it needs. This helps prevent or relieve anginal attacks and improve the quality of life of the client.
Choice D reason: Increasing the strength of myocardial contraction is not the therapeutic effect of atenolol for coronary artery disease. Atenolol does not increase the strength of myocardial contraction, but rather decreases it. Increasing the strength of myocardial contraction would increase the oxygen demand of the heart and worsen the angina. Atenolol aims to reduce the oxygen demand of the heart and improve the blood supply to the heart.
Correct Answer is D
Explanation
Choice A reason: Cucumbers are not a good source of iron for the client with iron-deficiency anemia. Iron-deficiency anemia is a condition where the body does not have enough iron to produce hemoglobin, the protein that carries oxygen in the red blood cells. Cucumbers are mostly water and have very little iron content. The client should eat foods that are rich in iron, such as meat, poultry, fish, eggs, beans, and leafy green vegetables.
Choice B reason: Bran is not a good source of iron for the client with iron-deficiency anemia. Bran is the outer layer of cereal grains that contains fiber and some minerals, but not much iron. Bran can also interfere with the absorption of iron from other foods by binding to it and preventing it from entering the bloodstream. The client should avoid eating bran or other foods that contain phytates, oxalates, or tannins, which can reduce the bioavailability of iron.
Choice C reason: Celery is not a good source of iron for the client with iron-deficiency anemia. Celery is a low-calorie vegetable that has some vitamins and minerals, but very little iron. Celery also has a high water content and can fill up the stomach without providing much nutrition. The client should eat foods that are high in iron, such as meat, poultry, fish, eggs, beans, and leafy green vegetables.
Choice D reason: This is the correct answer. Spinach is a good source of iron for the client with iron-deficiency anemia. Spinach is a leafy green vegetable that has a high iron content and can help increase the hemoglobin level and the oxygen-carrying capacity of the blood. Spinach also has other nutrients, such as vitamin C, folate, and antioxidants, that can benefit the health of the client. The client should eat spinach and other foods that are high in iron, such as meat, poultry, fish, eggs, beans, and leafy green vegetables.
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