Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina?

Correct Answer: D

Rationale: Step 1: Chronic stable angina is chest pain relieved by rest or nitroglycerin due to reduced blood flow to the heart. Step 2: Choice D indicates pain relieved by nitroglycerin, a hallmark of angina. Step 3: Choices A, B, and C do not specifically confirm angina diagnosis. Summary: Choice D is correct as it directly aligns with the characteristic relief of angina pain with nitroglycerin. Choices A, B, and C do not provide direct confirmation of chronic stable angina.

Correct Answer: C

Rationale: The correct question to ask first is "Do you experience shortness of breath with basic activities?" because it directly assesses the client's current health status related to COPD, which is essential for immediate care. By prioritizing this question, the nurse can quickly evaluate the severity of the client's symptoms and determine the need for urgent intervention or adjustment of the care plan. This information is crucial for addressing the client's immediate respiratory needs and ensuring their safety. Choice A is incorrect because assessing the client's support system is important but not as urgent as evaluating their respiratory status. Choice B is also incorrect as understanding the disease is important but not as time-sensitive as assessing the client's current symptoms. Choice D is incorrect as knowing the medications the client is prescribed is important for overall care but does not address the immediate need for respiratory assessment.

Correct Answer: B

Rationale: The correct answer is B: Cool, clammy skin. Following a myocardial infarction, the client may experience hypotension due to decreased cardiac output. Cool, clammy skin indicates poor peripheral perfusion, a common manifestation of hypotension. This finding suggests inadequate blood flow to the skin. The other choices are incorrect because: A: A heart rate of 120 beats/min may indicate tachycardia, which is a compensatory mechanism to maintain cardiac output in response to hypotension. C: An oxygen saturation of 90% is below the normal range but is not a typical assessment finding related to hypotension after a myocardial infarction. D: A respiratory rate of 8 breaths/min is abnormally low but not directly related to hypotension post-myocardial infarction.

Correct Answer: B

Rationale: The correct answer is B, a 52-year-old in a tripod position using accessory muscles to breathe. This client is likely experiencing respiratory distress, which is a medical emergency in COPD. The tripod position and use of accessory muscles indicate increased work of breathing and potential respiratory failure, requiring immediate assessment and intervention to prevent further deterioration. Incorrect choices: A: Smoking history is relevant but does not indicate immediate respiratory distress. C: Dependent edema and clubbed fingers suggest advanced disease but not acute respiratory distress. D: Chronic cough and thick secretions are common in COPD but do not indicate acute respiratory compromise.

Correct Answer: C

Rationale: The correct answer is C: Is the delegated task permitted by law? This is the first question the nurse must ask before delegating medication administration to an unskilled assistant. The rationale is that delegation must comply with legal regulations to ensure patient safety and avoid legal implications. If the task is not permitted by law, the nurse should not delegate it. Choice A (Has the assistant been trained to perform the task?) is important but comes after ensuring the task is legally permitted. Choice B (Have I evaluated the patients response to this task?) is about patient assessment, not legality. Choice D (Is appropriate supervision available?) is relevant but should come after confirming the task's legality.