Nokea
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.
You may also like to solve these questions
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?
- A. Blood pressure increased from 98/42 mm Hg to 112/50 mm Hg
- B. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
- C. Oxygen saturation increased from 88% to 90%
- D. Pulse decreased from 100 beats/min to 80 beats/min
Correct Answer: D
Rationale: Beta blockers block the stimulation of beta-adrenergic receptors, reducing the sympathetic response and decreasing heart rate. A decrease in pulse from 100 beats/min to 80 beats/min is an expected effect of beta blockers, as they slow the heart rate and reduce cardiac output.
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.
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
- A. An 80-year-old male with a history of asthma
- B. A 32-year-old Asian-American male with colorectal cancer
- C. A 45-year-old American Indian female with diabetes mellitus
- D. A 53-year-old postmenopausal woman who is on hormone therapy
Correct Answer: C
Rationale: The incidence of coronary artery disease and hypertension is higher in American Indians than in other populations. Diabetes mellitus further increases the risk for cardiovascular disease in any population, making the 45-year-old American Indian female with diabetes mellitus the client with the greatest risk.
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?
- A. A 30-year-old female who describes her pain as a dull ache with numbness in her fingers
- B. A 40-year-old male who reports moderate pain that is worse on inspiration
- C. A 53-year-old female who reports substantial pain that radiates to her abdomen
- D. A 36-year-old female who reports substantial pain that radiates to her jaw
Correct Answer: D
Rationale: Substantial chest pain radiating to the jaw is a classic symptom of myocardial infarction, requiring immediate assessment. Pain described as dull, related to inspiration, or radiating to the abdomen is less specific for acute cardiac events.
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.