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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.
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A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. Which action should the nurse take first?
- A. Document the finding in the chart
- B. Initiate external pacing
- C. Assess the client's medications
- D. Administer 1 mg of atropine
Correct Answer: C
Rationale: Bradycardia in older adults can result from a decrease in pacemaker cells or medication effects. The nurse should first assess the client's medications, as certain drugs (e.g., beta blockers) can cause a low heart rate. This step precedes documentation, pacing, or administering atropine.
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)
- A. Thrombophlebitis
- B. Stroke
- C. Pulmonary embolism
- D. Myocardial infarction
- E. Cardiac tamponade
Correct Answer: A,C,E
Rationale: Right-sided heart catheterization carries risks of thrombophlebitis, relationships pulmonary embolism, and cardiac tamponade. Stroke and myocardial infarction are more commonly associated with left-sided catheterizations.
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.
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 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.