Which statement, made by the client diagnosed with unstable angina, reflects an understanding of the nurse's discharge teaching?

"This type of pain is caused by spasm in my coronary arteries."

"Taking my beta blocker before exercising will prevent this pain."

"I should seek immediate medical attention when I experience pain."

"My pain will be relieved after I sit down and rest."

Answer and Explanation

The Correct Answer is C

Choice A Reason
While coronary artery spasm can cause chest pain, it is not the typical cause of unstable angina. Unstable angina is generally due to atherosclerotic heart disease, where plaque buildup in the coronary arteries restricts blood flow. This statement does not fully reflect an understanding of the condition.

Choice B Reason
Beta blockers are often prescribed to manage angina as they reduce the heart's workload and oxygen demand. However, they do not always prevent angina pain, especially in the case of unstable angina, which can occur unpredictably and not just during exertion. This statement shows partial understanding but lacks the urgency associated with unstable angina.

Choice C Reason
Seeking immediate medical attention when experiencing angina pain is crucial, especially in the case of unstable angina, which can signal an impending heart attack. This statement indicates that the client understands the seriousness of their condition and the need for prompt action.

Choice D Reason
While rest can help alleviate stable angina pain, unstable angina is less predictable and may not be relieved by rest. This type of angina requires medical evaluation to prevent more serious complications, such as myocardial infarction. This statement does not convey an adequate understanding of the condition.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice a reason:
Assessing capillary refill and the color of the extremity is essential for determining the vascular status of the limb. A normal capillary refill time is less than 2 seconds and indicates good blood flow. The color should be consistent with the rest of the body, without pallor or cyanosis, which could indicate compromised circulation.

Choice b reason:
Checking pedal pulses is another critical aspect of assessing vascular integrity. The presence of strong and equal pulses in both feet suggests that the blood supply to the lower extremities is not compromised.

Choice c reason:
While the ACE wrap and Velcro boot are part of the postoperative management to provide support and protection to the affected limb, and hanging weights might be used for traction, these are not part of the physiological assessment of the extremity.

Choice d reason:
Monitoring pin sites for signs of infection, such as redness, swelling, or discharge, is crucial in a client with ORIF. Infection can lead to complications that may affect the healing process and the integrity of the fixation.

Choice e reason:
Evaluating the temperature, sensation, and movement of toes helps in assessing for potential nerve damage or compartment syndrome. Any changes in these parameters should be reported immediately as they may signify serious complications.

A. Place the client on 2L via nasal cannula. B. Obtain a blood glucose. C. Call the physician for an order for a stat arterial blood gas to be drawn. D. Request an order for lorazepam.

Correct Answer is C

Explanation

Choice a reason:
Placing the client on 2L via nasal cannula is a common intervention for hypoxemia, but with the client's pulse oximetry at 88%, which is below the normal range of 95-100%, and the presence of tachypnea, a more immediate assessment of the client's respiratory status is warranted. Oxygen therapy should be guided by the results of arterial blood gas (ABG) analysis to tailor the treatment to the client's specific needs.

Choice b reason:
Obtaining a blood glucose level is not the most immediate concern in the context of altered mental status and respiratory distress. While it is important to rule out hypoglycemia as a cause of altered mental status, the primary concern indicated by the vital signs is the client's respiratory condition.

Choice c reason:
Calling the physician for an order for a stat arterial blood gas is the most appropriate action. The ABG will provide detailed information about the client's oxygenation, carbon dioxide levels, and acid-base balance. This is crucial for a client with a new onset change in mental status and tachypnea, as it can indicate respiratory failure or other serious complications of pneumonia.

Choice d reason:
Requesting an order for lorazepam is not appropriate given the client's current respiratory status. Lorazepam, a benzodiazepine, can depress the central nervous system and respiratory drive, potentially worsening the client's hypoxemia and respiratory effort.

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Which statement, made by the client diagnosed with unstable angina, reflects an understanding of the nurse's discharge teaching?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who sustained a compound fracture of the right tibia/fibula postoperative ORIF (open reduction internal fixation). A complete assessment of the affected extremity would include:

Correct Answer is ["A","B","D","E"]

Explanation

During an assessment of an anxious client diagnosed with right lower lobe pneumonia, the nurse notes a new onset change in mental status and tachypnea. The latest vital signs for the client are T: 98.4 F; HR: 108; RR: 28; BP: 144/90; Pulse ox: 88%. What is the priority nursing action?

Correct Answer is C

Explanation

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