Nokea
A client with unstable angina receives routine applications of nitroglycerin ointment. The nurse should delay the next dose if the client has:
- A. atrial fibrillation.
- B. A systolic blood pressure below 90 mm Hg.
- C. A headache.
- D. Skin redness at the current site.
Correct Answer: B
Rationale: The correct answer is B because a systolic blood pressure below 90 mm Hg indicates hypotension, which can be exacerbated by nitroglycerin causing further blood pressure drop. Delaying the dose allows the blood pressure to stabilize.
A: Atrial fibrillation is not a contraindication for nitroglycerin use.
C: Headache is a common side effect of nitroglycerin but does not require delaying the dose.
D: Skin redness at the current site may indicate a local reaction but does not necessarily require delaying the dose.
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The nurse obtains the following data when assessing a patient who experienced an ST- segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider?
- A. The troponin level is elevated.
- B. The patient denies having a heart attack.
- C. Bilateral crackles in the mid-lower lobes.
- D. Occasional premature atrial contractions (PACs).
Correct Answer: C
Rationale: The correct answer is C, bilateral crackles in the mid-lower lobes. This finding indicates potential heart failure, a serious complication post-STEMI. Reporting this promptly to the healthcare provider allows for timely intervention to prevent further deterioration. Choice A, an elevated troponin level, is expected post-STEMI and may not require immediate action. Choice B, the patient denying a heart attack, is not as critical as the physical assessment findings. Choice D, occasional PACs, is common and may not be directly related to the patient's current condition.
You have given morphine sulfate 4 mg IV to a patient who is having an AMI. When evaluating the response 5 minutes after giving the medication, which of these data indicate a need for immediate further action?
- A. The blood pressure decreases from 114/65 to 106/58.
- B. The respiratory rate drops from 18 to 12 breaths/minute.
- C. The patient complains of feeling lightheaded and dizzy.
- D. The patient still has chest pain at a level 1 (0-10 scale).
Correct Answer: B
Rationale: The correct answer is B because a significant drop in respiratory rate from 18 to 12 breaths/minute after administering morphine sulfate can indicate respiratory depression, a serious side effect. This requires immediate attention to prevent further complications like hypoxia or respiratory arrest. Choices A, C, and D do not indicate immediate need for action as a slight decrease in blood pressure, feeling lightheaded, and mild chest pain are expected side effects of morphine administration and can be managed with appropriate interventions.
The client has a decreased cardiac output. Which things can increase the client’s cardiac output? Select all that apply.
- A. Decreased heart rate
- B. Increased heart rate
- C. Increased blood volume
- D. Decreased venous return to the heart
Correct Answer: B
Rationale: The correct answer is B: Increased heart rate. Increasing heart rate can help compensate for decreased cardiac output by improving the heart's efficiency in pumping blood. This allows for more blood to be pumped out of the heart per minute, ultimately increasing cardiac output.
Decreased heart rate (choice A) would further decrease cardiac output by reducing the number of heartbeats per minute. Increased blood volume (choice C) can lead to increased preload and potentially worsen cardiac output in a compromised heart. Decreased venous return to the heart (choice D) reduces the amount of blood returning to the heart, which can also decrease cardiac output.
A key diagnostic test for heart failure is:
- A. serum potassium.
- B. B-type natriuretic peptide.
- C. Troponin I
- D. cardiac enzymes.
Correct Answer: B
Rationale: The correct answer is B: B-type natriuretic peptide. BNP is a hormone released by the heart in response to increased ventricular pressure and volume overload, which are characteristic of heart failure. Elevated levels of BNP indicate heart failure. Serum potassium (A) is not a specific diagnostic test for heart failure. Troponin I (C) and cardiac enzymes (D) are markers of cardiac damage, not heart failure.
A newly admitted patient, diagnosed with a myocardial infarction and left ventricular heart failure might exhibit which of the following physical symptoms? Choose all that apply.
- A. Jugular vein distention
- B. Hepatomegaly
- C. Dyspnea
- D. Crackles
Correct Answer: A
Rationale: Rationale: Jugular vein distention is a common physical symptom in patients with left ventricular heart failure due to increased central venous pressure. This is caused by the heart's inability to effectively pump blood, leading to backflow and congestion in the venous system. Hepatomegaly is less likely to be a direct physical symptom and is more indicative of chronic liver disease. Dyspnea and crackles are also common in heart failure, but they are more related to pulmonary congestion and fluid accumulation in the lungs, rather than a direct physical symptom. Therefore, the correct answer is A.