Nokea
During the assessment, the nurse identifies crackles in the lungs and an S3 heart sound. Which complication of MI should the nurse suspect and further investigate?
- A. Pericarditis
- B. Heart failure
- C. Ventricular aneurysm
- D. Papillary muscle dysfunction
Correct Answer: B
Rationale: Crackles and S3 indicate heart failure.
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As the cardiac-vascular nurse prepares to administer an experimental cardiac drug to a patient who is participating in a research study, the patient states that they no longer want the medication. The nurse advises the patient that:
- A. participation in the study is critical to improving the quality of patient outcomes.
- B. the medication dose has been scheduled for administration.
- C. the primary investigator will speak with the patient about their decision.
- D. they have the right to refuse the medication and to withdraw from the study.
Correct Answer: D
Rationale: Patients have the right to refuse treatment or withdraw from a study at any time.
You are working with an experienced nursing assistant and LPN/LVN in caring for a group of patients. You have developed a nursing diagnosis of Activity Intolerance related to fatigue and chest pain for a patient who had an acute myocardial infarction 3 days ago. Which of these nursing activities included in the care plan is best delegated to the LPN/LVN?
- A. Administer nitroglycerin (Nitro-Stat) if chest discomfort occurs during patient activities.
- B. Monitor pulse, blood pressure, and oxygen saturation before and after patient ambulation.
- C. Teach the patient energy conservation techniques to decrease myocardial oxygen demand.
- D. Explain the rationale for alternating rest periods with exercise to the patient and family.
Correct Answer: B
Rationale: Monitoring vital signs is within the scope of practice for an LPN/LVN and does not require advanced assessment skills.
An evaluation of Mrs. M.'s response to anticoagulant therapy for her arterial occlusion should include
- A. increased claudication
- B. decreased blood pressure
- C. compliance to skin care
- D. improvement of symptoms
Correct Answer: D
Rationale: Improvement in symptoms is a key indicator of effective anticoagulant therapy.
The client on amiodarone develops pulmonary fibrosis. What action should the nurse take?
- A. Notify the healthcare provider immediately.
- B. Continue the medication and monitor lung function.
- C. Discontinue the medication and start oxygen therapy.
- D. Reduce the dose and monitor respiratory status.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Pulmonary fibrosis is a serious side effect of amiodarone.
2. Immediate notification of the healthcare provider is necessary to address this potentially life-threatening complication.
3. The healthcare provider will need to evaluate the client's condition, consider alternative treatments, and adjust the care plan accordingly.
Summary of incorrect choices:
B. Continuing the medication without intervention can worsen the pulmonary fibrosis.
C. Discontinuing the medication is necessary, but oxygen therapy alone may not address the underlying issue.
D. Reducing the dose may not be sufficient to manage the pulmonary fibrosis and delaying provider notification can lead to further complications.
What test uses high-frequency sound waves to create images of the heart, allowing doctors to assess its structure and function?
- A. Echocardiogram
- B. MRI
- C. CT scan
- D. X-ray
Correct Answer: A
Rationale: The correct answer is A: Echocardiogram. An echocardiogram uses high-frequency sound waves to create detailed images of the heart's structure and function in real-time. It is a non-invasive and safe diagnostic tool commonly used to assess heart health. MRI (B) uses magnetic fields and radio waves, CT scan (C) uses X-rays, and X-ray (D) uses electromagnetic radiation, but they do not provide the same level of detail and real-time assessment of the heart as an echocardiogram does.