A client with ascites and peripheral edema is at risk for impaired ski

Adult Health II Respiratory NCLEX Questions

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Question 1 of 5.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:

A. Institute range-of-motion (ROM) exercise every 4 hours.

B. Massage the abdomen once a shift.

C. Use an alternating air pressure mattress.

D. Elevate the lower extremities.

Explanation: An alternating air pressure mattress (C) prevents pressure ulcers in clients with edema and ascites. ROM exercises (A) and elevation (D) are supportive but secondary. Abdominal massage (B) is not indicated.

Question 2 of 5.

When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI), the nurse explains that the purpose of the drug is to:

A. Help keep him well hydrated.

B. Dissolve clots that he may have.

C. Prevent kidney failure.

D. Treat potential cardiac arrhythmias.

Explanation: Thrombolytic drugs dissolve clots in coronary arteries, restoring blood flow to the myocardium during an MI, reducing infarct size and improving outcomes.

Question 3 of 5.

Alteplase recombinant, or tissue plasminogen activator (t-PA), is administered during the first 6 hours after onset of myocardial infarction (MI) to:

A. Control chest pain.

B. Reduce coronary artery vasospasm.

C. Control the arrhythmias associated with MI.

D. Revascularize the blocked coronary artery.

Explanation: t-PA dissolves clots in the coronary artery, restoring blood flow (revascularization) to the ischemic myocardium, critical within the first 6 hours of MI.

Question 4 of 5.

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by:

A. Antispasmodic effects on the pericardium.

B. Causing an increased myocardial oxygen demand.

C. Vasodilation of peripheral vasculature.

D. Improved conductivity in the myocardium.

Explanation: Nitroglycerin causes vasodilation of peripheral and coronary vasculature, reducing preload and myocardial oxygen demand, relieving angina.

Question 5 of 5.

When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply.

A. Becoming increasingly short of breath at rest.

B. Weight gain of 2 lb or more in 1 day.

C. High intake of sodium for breakfast.

D. Having to sleep sitting up in a reclining chair.

E. Weight loss of 2 lb in 1 day.

Explanation: Shortness of breath at rest (A), weight gain of 2 lb or more in 1 day (B), and sleeping sitting up (D) indicate worsening heart failure, requiring physician notification.