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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.
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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 reviews a client's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.)
- A. Total cholesterol: 280 mg/dL
- B. High-density lipoprotein cholesterol: 50 mg/dL
- C. Triglycerides: 200 mg/dL
- D. Serum albumin: 4 g/dL
- E. High-density lipoprotein cholesterol: 30 mg/dL
Correct Answer: A,C,E
Rationale: Elevated total cholesterol (280 mg/dL), elevated triglycerides (200 mg/dL), and low high-density lipoprotein cholesterol (30 mg/dL) are associated with increased risk of atherosclerosis. Serum albumin is not related to atherosclerosis risk, and an HDL of 50 mg/dL is within normal limits.
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.
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this client's teaching?
- A. The best way to lose weight is a high-protein, low-carbohydrate diet
- B. Follow the American Heart Association guidelines for nutrition
- C. A nutritionist will provide you with information about your new diet
- D. If you exercise more frequently, you won't need to change your diet
Correct Answer: B
Rationale: Clients at high risk for coronary artery disease should follow the American Heart Association guidelines, which emphasize a balanced diet low in saturated fats and high in fruits, vegetables, and whole grains to reduce cardiovascular risk.