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The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse?
- A. The 44-year-old client diagnosed with a myocardial infarction.
- B. The 65-year-old client admitted with unstable angina.
- C. The 75-year-old client scheduled for a cardiac catheterization.
- D. The 50-year-old client complaining of chest pain.
Correct Answer: C
Rationale: A client scheduled for cardiac catheterization (C) is stable, suitable for a new graduate. MI (A), unstable angina (B), and chest pain (D) require experienced care.
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The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure?
- A. An elevated B-type natriuretic peptide (BNP).
- B. An elevated creatine kinase (CK-MB).
- C. A positive D-dimer.
- D. A positive ventilation/perfusion (V/Q) scan.
Correct Answer: A
Rationale: Elevated BNP (A) is specific to heart failure, reflecting ventricular stress. CK-MB (B) indicates myocardial infarction, D-dimer (C) suggests clotting, and V/Q scan (D) is for pulmonary embolism.
Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply.
- A. Encourage a low-fat, low-cholesterol diet.
- B. Instruct the client to walk 30 minutes a day.
- C. Decrease the salt intake to two (2) g a day.
- D. Refer to a counselor for stress reduction techniques.
- E. Teach the client to increase fiber in the diet.
Correct Answer: A,B,D,E
Rationale: Low-fat/cholesterol diet (A), walking (B), stress reduction (D), and high-fiber diet (E) reduce CAD risk. Salt restriction (C) is more specific to CHF or hypertension.
Which nursing diagnosis would be priority for the client diagnosed with myocarditis?
- A. Anxiety related to possible long-term complications.
- B. High risk for injury related to antibiotic therapy.
- C. Increased cardiac output related to valve regurgitation.
- D. Activity intolerance related to impaired cardiac muscle function.
Correct Answer: D
Rationale: Myocarditis impairs cardiac function, making activity intolerance (D) the priority due to reduced cardiac output. Anxiety (A), injury (B), and increased output (C) are less immediate or incorrect.
The unlicensed assistive personnel (UAP) tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first?
- A. Tell the UAP to go take the client's vital signs.
- B. Ask the UAP to have the telemetry nurse read the strip.
- C. Notify the client's health-care provider.
- D. Go to the room and assess the client's chest pain.
Correct Answer: D
Rationale: Chest pain in CAD requires immediate nurse assessment (D) to determine severity and cause. Vital signs (A), telemetry (B), and notifying HCP (C) follow assessment.
The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor?
- A. The client admitted for diagnostic tests to rule out valvular heart disease.
- B. The client three (3) days post-myocardial infarction being discharged tomorrow.
- C. The client exhibiting supraventricular tachycardia (SVT) on telemetry.
- D. The client diagnosed with atrial fibrillation who has an INR of five (5).
Correct Answer: A
Rationale: Diagnostic testing for valvular disease (A) is stable, suitable for a new graduate. Post-MI (B), SVT (C), and high INR (D) require experienced care.