A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?
- A. MI only occurs with exertion.
- B. Stable angina can occur for longer than 30 minutes.
- C. Stable angina can be relieved with rest and nitroglycerin.
- D. The pain of an MI lasts less than 15 minutes.
Correct Answer: C
Rationale: Stable angina is usually relieved within 3-5 minutes by rest or nitroglycerin, while MI pain is more prolonged and severe and not relieved by these measures.
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A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?
- A. Atropine
- B. Furosemide
- C. Heparin
- D. Dexamethasone
Correct Answer: C
Rationale: Heparin is an anticoagulant used in the initial treatment of pulmonary embolism to prevent further clot formation.
A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?
- A. Tape the connections on the client's chest tube.
- B. Position the client in a supine position.
- C. Strip the client's chest tube every 2 hours.
- D. Place the chest tube drainage system above the level of the client's heart.
Correct Answer: A
Rationale: Taping connections maintains a closed system and prevents air leaks that could cause pneumothorax.
A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply).
- A. Hypoxemia
- B. Confusion
- C. Dyspnea
- D. Bradycardia
- E. Hypocarbia
Correct Answer: A,B,C,E
Rationale: These are common manifestations of ARF reflecting impaired gas exchange and cerebral effects of abnormal blood gases.
A nurse is caring for a client who has cirrhosis of the liver. Which of the following medications should the nurse anticipate may be ordered for this client? (Select all that apply.)
- A. Beta-blocking agent
- B. Diuretic
- C. Opioid analgesic
- D. Lactulose
- E. Sedative
Correct Answer: A,B,D
Rationale: Beta-blockers reduce portal pressure, diuretics manage ascites, and lactulose treats hepatic encephalopathy.
A client is admitted to the emergency department after sustaining multiple rib fractures in a motor vehicle accident. Upon assessment, the nurse notes that the client has flail chest. Which of the following signs and symptoms are associated with this condition? (Select all that apply.)
- A. Bradycardia
- B. Anxiety
- C. Dyspnea
- D. Unequal chest expansion
- E. Hypotension
- F. Paradoxical chest movement
Correct Answer: B,C,D,E,F
Rationale: Flail chest causes respiratory distress, paradoxical movement, and can lead to shock.
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