Nokea
A 45-year-old client is admitted to the medical telemetry unit to observe for possible dysrhythmias. After waking in the morning, the client asks the nurse for coffee. Which of the following would be the best response by the nurse?
- A. Hot beverages are not allowed because of the condition of your heart.
- B. Coffee is not included in your diet ordered by your health care provider (HCP).
- C. We don't have coffee on the unit. I can bring you some tea if you would like.
- D. Currently, you cannot have coffee as it contains caffeine, which can adversely affect your heart.
Correct Answer: D
Rationale: Caffeine can exacerbate dysrhythmias by stimulating the heart, making it contraindicated in this context.
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The nurse in the medical-surgical unit is observing the telemetry monitor for assigned clients. Which client condition change requires immediate notification to the primary healthcare provider (PHCP)? A client
- A. with normal sinus rhythm (NSR), who has had three premature ventricular contractions (PVCs) in the past hour.
- B. recovering from cardiac catheterization and has had two brief runs of ventricular tachycardia (VT).
- C. with atrial fibrillation, whose heart rate decreased from 113 to 95 beats per minute.
- D. who has developed sinus tachycardia (ST) following the application of nitroglycerin paste.
Correct Answer: B
Rationale: Ventricular tachycardia is life-threatening and requires immediate PHCP notification, unlike the other less urgent findings.
The nurse is discharging a client with heart failure who is prescribed digoxin and furosemide. Which of the following laboratory tests must the client have monitored due to this combination of prescribed medications?
- A. Fecal occult blood
- B. Serum electrolytes
- C. Urinalysis
- D. Glycosylated hemoglobin
Correct Answer: B
Rationale: Furosemide can cause hypokalemia, increasing digoxin toxicity risk, so serum electrolytes (especially potassium) must be monitored.
Which of the following findings would the nurse expect to observe in a client who has developed cardiac tamponade? Select all that apply.
- A. Unilateral crackles
- B. Systolic murmur
- C. Bradycardia
- D. Jugular venous distention
- E. Hypotension
Correct Answer: D,E
Rationale: Unilateral crackles suggest pulmonary issues, not tamponade. B: Incorrect - Systolic murmur is not specific to tamponade. C: Incorrect - Tachycardia, not bradycardia, is typical in tamponade due to compensatory mechanisms. D: Correct - Jugular venous distention occurs due to increased venous pressure. E: Correct - Hypotension results from reduced cardiac output in tamponade.
The nurse is caring for a client with the below tracing on the electrocardiogram (ECG). The nurse should anticipate which prescription from the primary healthcare provider (PHCP)?
- A. captopril
- B. atropine
- C. adenosine
- D. diltiazem
Correct Answer: B
Rationale: Atropine is used to treat bradycardia, which may be indicated by certain ECG tracings showing slow heart rates. Captopril is an ACE inhibitor for hypertension or heart failure, adenosine is used for supraventricular tachycardia, and diltiazem is a calcium channel blocker for rate control in atrial arrhythmias.
The nurse is caring for a client and upon initial evaluation the nurse suspects femoral artery occlusion. The nurse should take which action?
- A. Elevate the affected leg
- B. Apply a cold compress
- C. Notify the primary healthcare provider (PHCP)
- D. Perform passive range of motion to the affected leg
Correct Answer: C
Rationale: Femoral artery occlusion is a medical emergency requiring immediate notification of the PHCP for vascular intervention.