Nokea
If the client's severe chest pain is typical of other people who experience myocardial infarction (MI), the client is most likely to tell the nurse that the discomfort radiates to which area?
- A. Flank
- B. Groin
- C. Abdomen
- D. Shoulder
Correct Answer: D
Rationale: MI pain typically radiates to the shoulder, arm, or jaw due to referred pain from cardiac ischemia.
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Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)?
- A. Creatine kinase (CK-MB).
- B. Lactate dehydrogenase (LDH).
- C. Troponin.
- D. White blood cells (WBCs).
Correct Answer: C
Rationale: Troponin (C) rises within 3–4 hours post-MI, making it the earliest marker. CK-MB (A) rises in 4–6 hours, LDH (B) in 24–48 hours, and WBCs (D) are nonspecific.
After the femoral artery has been cannulated and the client is returned to the room, what should the nurse plan to do first?
- A. Palpate the client's distal peripheral pulses10 pulses.
- B. Auscultate the client's heart and breath sounds.
- C. Percuss all four quadrants of the client's abdomen.
- D. Inspect the skin integrity in the client's groin.
Correct Answer: A
Rationale: Palpating distal pulses first ensures adequate circulation post-catheterization, detecting complications like arterial occlusion.
The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include?
- A. Instruct the client to take a cough suppressant if a cough develops.
- B. Teach the client how to prevent orthostatic hypotension.
- C. Encourage the client to eat bananas to increase potassium level.
- D. Explain the importance of taking the medication with food.
Correct Answer: B
Rationale: ACE inhibitors cause hypotension, so teaching prevention of orthostatic hypotension (B) is critical. Cough suppressants (A) are inappropriate for ACE inhibitor cough, bananas (C) are unnecessary unless hypokalemia exists, and food (D) is not required.
The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement?
- A. Instruct the client to keep a diary of activity, especially when having chest pain.
- B. Discuss the need to remove the Holter monitor during a.m. care and showering.
- C. Explain that all medications should be withheld while wearing a Holter monitor.
- D. Teach the client the importance of decreasing activity while wearing the monitor.
Correct Answer: A
Rationale: A diary (A) correlates symptoms with ECG changes on the Holter monitor. Removal (B) is incorrect, medications (C) continue, and decreasing activity (D) is unnecessary.
Where is the correct placement for the nurse's hands before administering cardiac compressions?
- A. On the lower half of the sternum
- B. On the lower half of the xiphoid process
- C. Over the costal cartilage
- D. Directly above the manubrium
Correct Answer: A
Rationale: Hands are placed on the lower half of the sternum (center of the chest) for effective CPR compressions.