Nokea
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
- A. Perform a 12-lead ECG
- B. Determine if pain radiates to the left arm
- C. Check the client's blood pressure
- D. Auscultate heart tones
Correct Answer: A
Rationale: ECG is the primary diagnostic tool for MI, showing characteristic ST changes.
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A client is receiving continuous enteral nutrition through a nasogastric small-bore silicone feeding tube. What should the nurse plan for when this client has a computed tomography (CT) scan ordered?
- A. Ask the healthcare provider to re-schedule the scan
- B. Send a suction catheter with the client in case of aspiration during the scan
- C. Shut the feeding off 30-60 minutes before the scan
- D. Connect the feeding tube to continuous suction before and during the exam
Correct Answer: C
Rationale: Stopping feeding 30-60 minutes before the scan reduces aspiration risk and prevents stomach contents from interfering with imaging.
A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). Which of the following medications should the nurse plan to administer after the initial acute phase to manage the client's pain and anxiety?
- A. Nitroglycerin
- B. Aspirin
- C. Oxygen
- D. Morphine
Correct Answer: D
Rationale: Morphine is used for pain/anxiety management post-MI after acute interventions.
A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?
- A. MI only occurs with exertion.
- B. Stable angina can occur for longer than 30 minutes.
- C. Stable angina can be relieved with rest and nitroglycerin.
- D. The pain of an MI lasts less than 15 minutes.
Correct Answer: C
Rationale: Stable angina is usually relieved within 3-5 minutes by rest or nitroglycerin, while MI pain is more prolonged and severe and not relieved by these measures.
A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Occasional bubbling in the water-seal chamber
- B. No reports of pleuritic chest pain
- C. No tidaling in the water-seal chamber
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Absence of tidaling indicates lung re-expansion as intrapleural pressure equalizes.
A nurse is caring for a client who has a pulmonary embolism and has been on a heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
- A. Both heparin and warfarin work together to dissolve the clots.
- B. Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level.
- C. The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay.
- D. I will call the provider to get a prescription for discontinuing the IV heparin today.
Correct Answer: B
Rationale: Overlap therapy is needed because warfarin has delayed onset (3-5 days) while heparin provides immediate anticoagulation.