The nurse is caring for a patient who has aortic stenosis. During data collection, which of these manifestations would indicate to the nurse that the patient is experiencing myocardial oxygen deficiency?
a. Jugular vein distention
b. Sacral edema
c. Angina
d. Pericardial friction rub
ANS: C
Angina results if cardiac oxygen needs are not met.
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The nurse is caring for an eight-year-old child who has been in a car accident, has a head injury, and is in the ICU. The nurse sees the child pulling on the IV line. What action should the nurse take?
1. Sedate the child as needed. 2. Place soft wrist restraints on the child. 3. Ask the parents to watch the child closely at all times. 4. Tell the child not to pull on the IV line.
Because many illnesses are now controlled rather than cured, the number of people with chronic, debilitating illnesses has increased. Home care nurses provide needed assessment and evaluations of these illnesses to prevent:
a. deaths. b. increased morbidity. c. increased hospitalization. d. acute episodes.
The client is 1 day postoperative from a total hip replacement and has an abduction pillow in place. What is the best nursing action or intervention to prevent complications from this de-vice?
A. Apply lotion to the client's legs daily. B. Turn the client only to the nonoperative side. C. Assess the client's skin under the straps every 2 hours. D. Change the client's antiembolic stockings every 24 hours.
A patient has been taking isoniazid (Nydrazid) for 4 months for latent tuberculosis. The patient reports bilateral tingling and numbness of the hands and feet, as well as feeling clumsy. The nurse expects the provider to:
a. discontinue the isoniazid. b. lower the isoniazid dose and add rifampin. c. order pyridoxine 100 mg per day. d. recheck the tuberculin skin test to see whether it worsens.