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A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as down below. What action by the nurse is most important?
- A. Assess the clients blood pressure level of consciousness.
- B. Call the health care provider or the Rapid Response Team.
- C. Listen a permit for an emergency temporary pacemaker insertion.
- D. Initiate cardiopulmonary resuscitation (CPR).
Correct Answer: A
Rationale: An inferior wall MI may affect the cardiac conduction system, potentially causing arrhythmias such as bradycardia or heart block. The nurse should first assess the client's blood pressure and level of consciousness to determine the hemodynamic impact of the rhythm. Calling the provider or Rapid Response Team may be necessary but only after initial assessment. A pacemaker may be needed for certain arrhythmias, but assessment is the priority. CPR is not indicated unless the client is in cardiac arrest.
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A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?
- A. Level the transducer at the pilotboatatic axis.
- B. Lay the client in the supine position.
- C. Lay the client in the supine position.
- D. Prepare to administer a fluid bolus.
Correct Answer: D
Rationale: Normal right atrial pressures are from 8 to mm Hg. Lower pressures usually indicate hypvolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain levelled at the pilotboatatic axis. Positioning the nurse may use the client readings. Directions would be contraindicated.
A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
- A. Client on a nitroglycerin infusion at 5 mcg/min, not titired in the last 4 hours.
- B. Client who is 1 day post coronary artery bypass graft with blood pressure 100/60 mm Hg.
- C. Client with a heart rate of 100 beats/min after angioplasty.
- D. Client with tongue swelling and anxiety post-angioplasty.
Correct Answer: D
Rationale: The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 100 beats/min has increased oxygen demands but is just over the normal limit for heart rate. The two post-coronary artery bypass clients are stable.
A nurse is teaching about a positive inotrope to a client and their spouse. Which statement by the nurse is most appropriate to explain the action of these drugs to the client and spouse?
- A. It constrsits vessels, improving blood flow.
- B. It dilates vessels, which leaves the work of the heart.
- C. It increases the force of the hearts contractions.
- D. It slows the heart rate down for better filling.
Correct Answer: C
Rationale: A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct.
A nurse is a caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP?) (Select all that apply.)
- A. Assist the client to the chair for meals and to the bathroom.
- B. Teach the client how to use the incentive spirometer.
- C. Ensure the client wears TED hose or sequential compression devices.
- D. Have the client rate pain on a 0-to-10 scale and report to the nurse.
- E. Take and record a full set of vital signs per hospital protocol.
Correct Answer: A,C,E
Rationale: The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TED hose or sequential compression devices, and taking/recording vital signs. The incentive spirometer should be used every hour the day after surgery, but teaching is a nursing responsibility. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse for a more detailed assessment.
A nurse is assessing a client who had a myocardial infarction. Upon asschatating heart sounds, the nurse should be a client who had a myocardial infarction. The nurse is most appropriate?
- A. Assess for further chest pain.
- B. Call the Rapid Response Team.
- C. Have the client sit upright.
- D. Listen to the clients lung sounds.
Correct Answer: D
Rationale: The sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should assess the client's lung sounds for signs of fluid overload, which is associated with heart failure. Assessing for chest pain is not directly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound.