A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

"I will take four nitroglycerin sublingual tablets if I have chest pain."

"I will have hot, dry, and flushed skin if I am having a heart attack."

"I will wait 30 minutes before taking action if I have heartburn."

"I will notify emergency response if I have sudden jaw pain."

Answer and Explanation

The Correct Answer is D

This response indicates that the client understands that sudden jaw pain can be a sign of a heart attack and requires immediate medical attention.

A. "I will take four nitroglycerin sublingual tablets if I have chest pain." This is an incorrect statement because taking four nitroglycerin sublingual tablets can lead to hypotension and can be life-threatening.

B. "I will have hot, dry, and flushed skin if I am having a heart attack." This is an incorrect statement because hot, dry, and flushed skin is not a typical sign of a heart attack.

C. "I will wait 30 minutes before taking action if I have heartburn." This is an incorrect statement because heartburn is not a symptom of angina and waiting 30 minutes to take action can lead to further complications.

Explanation: The client with angina should be educated about the signs and symptoms of a heart attack and when to seek medical attention. Jaw pain is one of the signs of a heart attack, and the client should seek emergency medical attention immediately.

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Correct Answer is A

Explanation

A change in pupil size can indicate an increase in intracranial pressure, which can lead to a life-threatening situation. The nurse should immediately report this finding to the provider.

Choice B is incorrect because difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice C is incorrect because inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice D is incorrect because right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Reasons why the other choices are not answers:

Choice B: Difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice C: Inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice D: Right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

A. Obtain a set of vital signs. B. Flex the client's knees and hips. C. Apply a moist saline dressing to the area. D. Elevate the head of the client's bed 20°.

Correct Answer is C

Explanation

The correct answer is c. Apply a moist saline dressing to the area.

Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.

Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.

Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.

Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.

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A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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