Nokea
If the client understands the nurse's explanation of the heart's conduction system, which structure will the client identify as the site of the natural pacemaker? Place an X over the correct site.
- A. Sinoatrial node
- B. Atrioventricular node
- C. Bundle of His
- D. Purkinje fibers
Correct Answer: A
Rationale: The sinoatrial (SA) node is the heart's natural pacemaker, initiating electrical impulses.
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The nurse anticipates that the client will most likely demonstrate which emotional response in relation to the development of heart failure?
- A. Depression
- B. Anxiety
- C. Anger
- D. Stoicism
Correct Answer: B
Rationale: Anxiety is common in CHF due to breathlessness and fear of disease progression.
During cardiopulmonary resuscitation (CPR), the nurse compresses the chest of an adult victim at which rate?
- A. No less than 15 compressions per minute
- B. No less than 40 compressions per minute
- C. No less than 80 compressions per minute
- D. No less than 100 compressions per minute
Correct Answer: D
Rationale: Adult CPR requires 100-120 compressions per minute to restore circulation effectively.
Which assessment finding should signal the nurse to withhold applying the client's nitroglycerin patch and notify the physician?
- A. The pressure of 99.8°F (37.6°C)
- B. Respiratory rate of 24 breaths/minute at rest
- C. Apical heart rate of 90 beats/minute
- D. Blood pressure of 94/62 mm Hg
Correct Answer: D
Rationale: A blood pressure of 94/62 mm Hg indicates hypotension, a contraindication for nitroglycerin, which can further lower blood pressure.
A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?
- A. Gallbladder disease
- B. Liver disease
- C. Myocardial infarction
- D. Skeletal muscle injury
Correct Answer: C
Rationale: AST is an enzyme released in response to tissue damage. The symptoms of chest pain and shortness of breath, along with elevated AST 24 hours later, are suggestive of myocardial infarction. AST rises after a myocardial infarction but may also rise with liver damage or skeletal muscle injury. Gallbladder disease typically presents with pain in the right scapula region and would not have an elevated AST.
An adult male is being evaluated for possible dysrhythmia and is to be placed on a Holter monitor. What instructions should the nurse give him to ensure that this test provides a comprehensive picture of his cardiac status?
- A. Remove the electrodes intermittently for hygiene measures.
- B. Exercise frequently while the monitor is in place.
- C. Keep a diary of all your activities while being monitored.
- D. Refrain from activities that precipitate symptoms.
Correct Answer: C
Rationale: Keeping a diary of activities correlates symptoms or dysrhythmias with specific triggers, providing a comprehensive picture for diagnosis.