A nurse is collecting data on a client who has coronary artery disease. Which of the following manifestations should the nurse anticipate? (Select All that Apply.)

Varicose veins

Chest pain

Palpitations

Shortness of breath

Heart murmur

Answer and Explanation

Correct Answer : B,C,D

A. Varicose veins are typically associated with venous insufficiency rather than coronary artery disease.
B. Chest pain, or angina, is a common symptom of coronary artery disease due to reduced blood flow to the heart muscle.
C. Palpitations can occur in clients with coronary artery disease as the heart compensates for decreased perfusion.
D. Shortness of breath can result from decreased cardiac output and oxygenation due to coronary artery disease.
E. A heart murmur is not a typical manifestation of coronary artery disease; it is more associated with valvular heart disease.

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Correct Answer is D

Explanation

A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.
B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.
C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.
D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.

A. Prevent bladder distention. B. Elevate the client's head. C. Provide analgesia for headaches. D. Monitor for elevated blood pressure.

Correct Answer is A

Explanation

A. Autonomic dysreflexia is often triggered by a noxious stimulus, such as bladder distention. Preventing bladder distention by ensuring regular bladder emptying can help prevent the condition.
B. Elevating the client's head is a response to autonomic dysreflexia but does not prevent it from occurring.
C. Providing analgesia for headaches addresses a symptom of autonomic dysreflexia but does not prevent it.
D. Monitoring for elevated blood pressure is important in detecting autonomic dysreflexia once it has started, but it does not prevent it.

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A nurse is collecting data on a client who has coronary artery disease. Which of the following manifestations should the nurse anticipate? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who is receiving digoxin to treat heart failure. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

Correct Answer is A

Explanation

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