Nokea
Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction?
- A. Midepigastric pain and pyrosis.
- B. Diaphoresis and cool, clammy skin.
- C. Intermittent claudication and pallor.
- D. Jugular vein distention and dependent edema.
Correct Answer: B
Rationale: MI causes diaphoresis and cool, clammy skin (B) due to sympathetic activation. Epigastric pain/pyrosis (A) suggest GI issues, claudication/pallor (C) indicate PAD, and JVD/edema (D) suggest heart failure.
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The client diagnosed with an ST elevation myocardial infarction (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which should the nurse implement first?
- A. Notify the health care provider (HCP).
- B. Assess what the client ate at the last meal.
- C. Request a STAT 12 lead electrocardiogram.
- D. Administer furosemide IVP.
Correct Answer: A
Rationale: Edema and crackles post-STEMI suggest heart failure; notifying the HCP (A) ensures timely intervention. Diet (B), ECG (C), and furosemide (D) follow HCP orders.
The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the Post Anesthesia Care Unit nurse implement?
- A. Assess the client's chest tube output.
- B. Monitor the client's chest dressing.
- C. Evaluate the client's endotracheal (ET) lip line.
- D. Keep the client's affected leg straight.
Correct Answer: D
Rationale: Valvuloplasty is performed via femoral access, so keeping the leg straight (D) prevents bleeding. Chest tubes (A), dressings (B), and ET tubes (C) are not involved.
The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented?
- A. Check the client for peripheral edema and make sure the client takes a diuretic early in the day.
- B. Monitor the client's potassium level and assess the client's intake of bananas and orange juice.
- C. Determine if the client has gained weight and instruct the client to keep the legs elevated.
- D. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.
Correct Answer: B
Rationale: Leg cramps in CHF may indicate hypokalemia from diuretics. Monitoring potassium and assessing potassium-rich food intake (B) is appropriate. Edema/diuretic timing (A), weight/elevation (C), and ambulation/stretching (D) are less directly related.
Which client would the nurse suspect of having a mitral valve prolapse?
- A. A 60-year-old female with congestive heart failure.
- B. A 23-year-old male with Marfan's syndrome.
- C. An 80-year-old male with atrial fibrillation.
- D. A 33-year-old female with Down syndrome.
Correct Answer: B
Rationale: Mitral valve prolapse is common in Marfan’s syndrome (B) due to connective tissue defects. CHF (A), atrial fibrillation (C), and Down syndrome (D) are not strongly associated.
Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease?
- A. Assess the client's radial pulse.
- B. Assess the client's serum potassium level.
- C. Assess the client's glucometer reading.
- D. Assess the client's pulse oximeter reading.
Correct Answer: B
Rationale: Loop diuretics cause hypokalemia, which can precipitate dysrhythmias in CAD. Assessing potassium (B) is critical. Pulse (A), glucose (C), and SpO2 (D) are less directly related.