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A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse suspect?
- A. Heart rate of 120 beats/min
- B. Cool, clammy skin
- C. Oxygen saturation of 90%
- D. Respiratory rate of 8 breaths/min
Correct Answer: A
Rationale: When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node, resulting in an increased heart rate. A heart rate of 120 beats/min is indicative of tachycardia, which is a compensatory mechanism for low blood pressure.
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Where should the nurse auscultate the aortic valve?
- A. Location A: Second intercostal space, right of sternum
- B. Location B: Second intercostal space, left of sternum
- C. Location C: Fifth intercostal space, midclavicular line
- D. Location D: Fourth intercostal space, left of sternum
Correct Answer: A
Rationale: The aortic valve is best auscultated in the second intercostal space just to the right of the sternum, where heart sounds related to aortic flow are most audible.
A nurse prepares a client for a pharmacologic stress echocardiogram. Which actionsadalafil should the nurse take when preparing this client for the procedure? (Select all that apply.)
- A. Obtain peripheral venous access
- B. Prepare for continuous blood pressure and pulse monitoring
- C. Administer the client's prescribed beta blocker
- D. Give the client nothing by mouth 3 to 6 hours before the procedure
- E. Explain to the client that dobutamine will simulate exercise for this examination
Correct Answer: A,B,D,E
Rationale: For a pharmacologic stress echocardiogram, the nurse should obtain IV access, monitor blood pressure and pulse continuously, ensure the client is NPO for 3-6 hours, and educate about dobutamine's role in simulating exercise. Beta blockers are typically held to avoid interference with the stress test.
A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. Which action should the nurse take first?
- A. Document the finding in the chart
- B. Initiate external pacing
- C. Assess the client's medications
- D. Administer 1 mg of atropine
Correct Answer: C
Rationale: Bradycardia in older adults can result from a decrease in pacemaker cells or medication effects. The nurse should first assess the client's medications, as certain drugs (e.g., beta blockers) can cause a low heart rate. This step precedes documentation, pacing, or administering atropine.
A nurse monitors a client 2 hours after a cardiac catheterization. Which findings would require immediate action? (Select all that apply.)
- A. Blood pressure of 142/88 mm Hg
- B. Serum potassium of 2.9 mEq/L
- C. Warmth and redness at the site
- D. Expanding hematoma
- E. Rhythm changes on the cardiac monitor
Correct Answer: B,D,E
Rationale: Hypokalemia (2.9 mEq/L), an expanding hematoma, and rhythm changes are serious complications requiring immediate action. Slightly elevated blood pressure and warmth/redness (if not severe) are less urgent in the immediate post-procedure period.
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
- A. I get short of breath when I climb stairs
- B. I see lights flashing in front of my eyes
- C. I have trouble remembering things
- D. I wake up to urinate multiple times at night
Correct Answer: A
Rationale: Dyspnea on exertion, such as shortness of breath when climbing stairs, is an early manifestation of heart failure due to reduced cardiac output during activity. The other symptoms are not specific to heart failure.