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Priority Decision: A patient is hospitalized after a successful resuscitation of an episode of sudden cardiac death (SCD). During the care of the patient, what nursing intervention is most important?
- A. Continuous ECG monitoring
- B. Auscultation of the carotid arteries
- C. Frequent assessment of heart sounds
- D. Monitoring of airway status and respiratory patterns
Correct Answer: A
Rationale: Continuous monitoring detects dysrhythmias.
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The patient is experiencing chest pain and pain radiating to his arms, jaw, and back. The provider diagnosed his condition as a myocardial infarction. The patient asks what happened to him. The best response is:
- A. You cannot tell him what has happened; he needs to wait for the provider to return and explain what is going on currently.
- B. His aortic valve was malformed at birth causing a disruption in blood flow.
- C. All patients who are overweight like him will have a heart attack.
- D. One or more arteries that supply blood to his heart are blocked, thereby preventing an adequate amount of blood from getting to his cardiac muscles.
Correct Answer: D
Rationale: A myocardial infarction occurs when there is a blockage in one or more arteries supplying blood to the heart.
The nurse is giving digoxin to a client. What is the most important parameter to check before administration?
- A. Heart rate
- B. Blood pressure
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: A
Rationale: Step 1: Digoxin is primarily used to treat heart conditions.
Step 2: Heart rate is crucial as digoxin can affect the heart rhythm.
Step 3: Monitoring heart rate ensures safety and effectiveness of digoxin.
Step 4: Blood pressure, respiratory rate, and oxygen saturation are important but not as directly impacted by digoxin.
What does the nurse teach the client who has had a mechanical valve placed?
- A. The PT must remain below 1.5 times the control value.
- B. The PTT must be higher than 2.5 times the control value.
- C. The INR must be maintained between 2.5 and 3.5 for anticoagulant monitoring
- D. The INR must be maintained below 2.5 for anticoagulant monitoring.
Correct Answer: C
Rationale: Mechanical valves require precise anticoagulation management, with an INR target range of 2.5-3.5 to prevent clotting.
In the patient with chest pain, which results can differentiate unstable angina from an MI?
- A. ECG changes present at the onset of the pain
- B. A chest x-ray indicating left ventricular hypertrophy
- C. Appearance of troponin in the blood 48 hours after the infarct
- D. Creatine kinase (CK)-MB enzyme elevations that peak 18 hours after the infarct
Correct Answer: A
Rationale: ECG changes distinguish unstable angina from MI.
What is a chronic inflammatory disease that affects the small airways in the lungs, leading to episodes of wheezing, breathlessness, and coughing?
- A. Asthma
- B. COPD
- C. Bronchitis
- D. Lung cancer
Correct Answer: A
Rationale: The correct answer is A: Asthma. Asthma is a chronic inflammatory disease that affects the small airways in the lungs, causing symptoms like wheezing, breathlessness, and coughing. The inflammation in the airways leads to narrowing and constriction, resulting in the characteristic symptoms of asthma. Asthma is typically triggered by various factors such as allergens, pollutants, exercise, or infections.
Summary of other choices:
B: COPD (Chronic Obstructive Pulmonary Disease) is a different condition characterized by irreversible airflow limitation due to chronic bronchitis and emphysema.
C: Bronchitis is an inflammation of the bronchial tubes, often caused by viral infections or smoking, but it does not specifically target the small airways like asthma.
D: Lung cancer is a malignancy that arises in the lungs and is not primarily associated with chronic inflammation of the small airways as seen in asthma.