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A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. What action should the nurse take?
- A. Obtain a prescription for pain medication.
- B. Have the client stop and lie back down in bed.
- C. Report the complaint to the healthcare provider.
- D. Instruct the client to continue getting out of bed and into a chair.
Correct Answer: B
Rationale: When a client with CAD experiences chest pain, it indicates myocardial ischemia. The nurse should have the client stop the activity and lie back down in bed to reduce the heart's oxygen demand, decrease myocardial workload, and prevent further ischemia. This action helps in improving blood flow to the heart and can potentially alleviate the chest pain.
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The client is being ambulated due to activity intolerance caused by bacterial endocarditis. How can the nurse determine that the client is best tolerating ambulation?
- A. Mild dyspnea after walking 10 feet
- B. Minimal chest pain rated 1 on a 1-to-10 pain scale
- C. Pulse rate that increases from 68 to 94 beats per minute
- D. Blood pressure that increases from 114/82 to 118/86 mm Hg
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The provider should place the highest priority on making sure that which is available at the bedside?
- A. Bedside commode
- B. Rolling shower chair
- C. Oxygen tubing and flowmeter
- D. Twelve-lead electrocardiogram (ECG) machine
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed?
- A. Strict bed rest for 24 hours
- B. Bathroom privileges and self-care activities
- C. Unrestricted activities because the client is monitored
- D. Unsupervised hallway ambulation with distances less than 200 feet
Correct Answer: B
Rationale: After being transferred from the CCU to the general medical unit with cardiac monitoring, the client with MI is typically prescribed bathroom privileges and self-care activities. This allows for gradual recovery and mobility while still being closely monitored, promoting the client's overall well-being and independence.
The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse implement when providing care for the client?
- A. Take daily weights and monitor trends.
- B. Encourage fluid intake to improve hydration.
- C. Elevate the legs above the level of the heart.
- D. Position the client supine with the head of the bed at 30 degrees.
Correct Answer: A
Rationale: Elevated BNP levels are indicative of heart failure, which often causes fluid retention and weight gain. Taking daily weights and monitoring trends allows the nurse to assess for changes in fluid status. This intervention helps in evaluating the effectiveness of the treatment plan and identifying worsening heart failure symptoms early.
The healthcare provider is preparing to assist in the care of a client who has just returned from coronary artery bypass graft (CABG) surgery. Which is the priority action?
- A. Monitor the client's urine output.
- B. Check the client's surgical dressing.
- C. Measure the client's blood pressure.
- D. Assess the client's level of consciousness.
Correct Answer: D
Rationale: Assessing the client's level of consciousness is the priority action post-CABG surgery to monitor for signs of cerebral hypoxia or other complications that require immediate intervention. Changes in the client's level of consciousness can indicate neurological deterioration, which is critical to address promptly in this postoperative period.