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A nurse is assessing a client who had a myocardial infarction. Upon asschatating heart sounds, the nurse should be a client who had a myocardial infarction. The nurse is most appropriate?
- A. Assess for further chest pain.
- B. Call the Rapid Response Team.
- C. Have the client sit upright.
- D. Listen to the clients lung sounds.
Correct Answer: D
Rationale: The sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should assess the client's lung sounds for signs of fluid overload, which is associated with heart failure. Assessing for chest pain is not directly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound.
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A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in which way? (Select all that apply.)
- A. Accompanied by shortness of breath
- B. Feelings of fear or anxiety
- C. Lasts longer than 15 minutes
- D. Not relieved by rest or nitroglycerin
- E. Triggered by exertion
Correct Answer: A,B,C,D
Rationale: The pain of a myocardial infarction is typically accompanied by shortness of breath, feelings of fear or anxiety, lasts longer than 15 minutes, and is not relieved by rest or nitroglycerin, unlike stable angina. Stable angina is often triggered by exertion, but MI pain can occur at rest.
A nurse is teaching about a positive inotrope to a client and their spouse. Which statement by the nurse is most appropriate to explain the action of these drugs to the client and spouse?
- A. It constrsits vessels, improving blood flow.
- B. It dilates vessels, which leaves the work of the heart.
- C. It increases the force of the hearts contractions.
- D. It slows the heart rate down for better filling.
Correct Answer: C
Rationale: A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct.
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be determined to response, please, and time. What action by the nurse is best?
- A. Assess the clients papillary responses.
- B. Request an neurologic consultation.
- C. Stop the infusion and call the provider.
- D. Take and document a full set of vital signs.
Correct Answer: C
Rationale: A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including papillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement on this client.
- A. Ensure the balloon does not remain wedged.
- B. Ensure the balloon does not remain wedged.
- C. Keep the client on strict NPO status.
- D. Maintain the client in a semi-Foolies position.
Correct Answer: B
Rationale: The balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings.
The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important?
- A. Wash hands and wear sterile gloves.
- B. Don a mask and gown.
- C. Prepare a sterile field.
- D. Use clean technique for the procedure.
Correct Answer: C
Rationale: Changing a sternal dressing requires maintaining a sterile environment to prevent infection, especially in a post-surgical client. Preparing a sterile field is the most important action to ensure sterility. Washing hands and wearing sterile gloves are part of the process but are secondary to establishing a sterile field. A mask and gown may be required depending on hospital protocol, but the sterile field is critical. Clean technique is not appropriate for this procedure.