Nokea
According to the nurse, when is the correct time to note the diastolic blood pressure reading?
- A. When the loud knocking sounds become muffled
- B. When the last loud knocking sound is heard
- C. When the swishing sound is a second
- D. When the swishing sound becomes faint
Correct Answer: B
Rationale: The diastolic blood pressure is recorded at the point when the last loud knocking sound (Korotkoff phase V) is heard, indicating the pressure at which blood flow is fully restored.
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The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement?
- A. Assess the apical heart rate for one (1) full minute.
- B. Notify the client's cardiac surgeon.
- C. Prepare the client for synchronized cardioversion.
- D. Determine if the client is having pain.
Correct Answer: D
Rationale: Sinus tachycardia post-CABG is often due to pain (D), which should be assessed first. Heart rate (A), notifying (B), and cardioversion (C) follow if needed.
The nurse informs the client that the correct way to administer nitroglycerin is to place one tablet where?
- A. The nurse is the first and check
- B. At the back of the throat
- C. Under the tongue
- D. Between the teeth
Correct Answer: C
Rationale: Sublingual nitroglycerin is placed under the tongue for rapid absorption into the bloodstream to relieve angina.
Before the cardiac catheterization and coronary arteriogram, it is essential for the nurse will be taken about any allergy to iodine or which other substance?
- A. Penicillin
- B. Morphine
- C. Shellfish
- D. Eggs
Correct Answer: C
Rationale: Shellfish allergies often indicate a risk of iodine sensitivity, which is critical since contrast dye used in arteriograms contains iodine.
A young adult with a history of rheumatic fever as a child is to have a cardiac catheterization. She asks the nurse why she must have a cardiac catheterization. The nurse's response is based on the understanding that cardiac catheterization can accomplish all of the following EXCEPT:
- A. assessing heart structures.
- B. determining oxygen levels in the heart chambers.
- C. evaluating cardiac output.
- D. obtaining a biopsy specimen.
Correct Answer: D
Rationale: Cardiac catheterization can assess heart structures, measure oxygen levels, and evaluate cardiac output, but obtaining a biopsy specimen is not a standard purpose of this procedure. Biopsies are typically performed via other methods, such as endomyocardial biopsy in specific cases.
Which client would most likely be misdiagnosed for having a myocardial infarction?
- A. A 55-year-old Caucasian male with crushing chest pain and diaphoresis.
- B. A 60-year-old Native American male with an elevated troponin level.
- C. A 40-year-old Hispanic female with a normal electrocardiogram.
- D. An 80-year-old Peruvian female with a normal CK-MB at 12 hours.
Correct Answer: C
Rationale: A 40-year-old Hispanic female with normal ECG (C) is most likely to be misdiagnosed, as women often present atypically and normal ECGs can occur in MI. Typical symptoms (A), elevated troponin (B), and normal CK-MB at 12 hours (D) are less likely to be missed.