Nokea
The client calls for the nurse after experiencing sharp chest pains that radiate to the left shoulder. All of the following interventions were prescribed on admission for treating chest pain. Which intervention should the nurse implement first?
- A. STAT 12-lead electrocardiogram (ECG)
- B. Oxygen 4 liters by nasal cannula
- C. Nitroglycerin 0.4 mg sublingual
- D. Morphine sulfate 2-4 mg IV prn
Correct Answer: B
Rationale: Oxygen should be available in the room and should be initiated first to enhance oxygen flow to the myocardium. ECG, nitroglycerin, and morphine are important but secondary to improving oxygenation in acute chest pain.
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The cardiac monitor of the client diagnosed with Prinzmetal’s angina shows a prolonged PR interval of 0.32 seconds. Which prescribed medication should the nurse question administering to the client?
- A. Isosorbide mononitrate 20 mg oral daily
- B. Amlodipine 10 mg oral daily
- C. Nitroglycerin 0.4 mg sublingual prn
- D. Atenolol 50 mg oral daily
Correct Answer: D
Rationale: Atenolol (Tenormin), a beta blocker, blocks stimulation of beta1 (myocardial)-adrenergic receptors, causing a reduction in BP and HR. A side effect of the medication is a prolongation of the PR interval (normal PR interval is 0.12 to 0.20 second). Continued use of the drug can result in heart block. The nurse should question administering atenolol. Other medications do not prolong the PR interval.
The nurse is caring for the client with varicose veins. Which action should indicate to the nurse that an expected outcome has been met?
- A. States will walk daily to promote venous return
- B. Reports decreased need for compression stockings
- C. States can finally stand for prolonged periods of time
- D. Chooses diet high in potassium and low in magnesium
Correct Answer: A
Rationale: Walking promotes venous return; verbalizing intent to increase activity indicates an expected outcome has been met for the client with varicose veins. Decreased stocking use, prolonged standing, and specific diets are not beneficial.
The client with a left anterior descending (LAD) 90% blockage has crushing chest pain that is unrelieved by taking sublingual nitroglycerin. Which ECG finding is most concerning and should alert the nurse to immediately notify the HCP?
- A. Q waves
- B. Flipped T waves
- C. Peaked T waves
- D. ST segment elevation
Correct Answer: D
Rationale: The nurse should be most concerned about ST elevation because it indicates an evolving MI. Q waves suggest a previous MI, flipped T waves indicate ischemia, and peaked T waves may indicate hyperkalemia, but ST elevation is the most acute and critical finding.
The client, returning from a coronary catheterization in which the femoral artery approach was used, sneezes. Which should be the nurse’s priority intervention?
- A. Palpate pedal pulses
- B. Measure vital signs
- C. Assess for urticaria
- D. Check the insertion site
Correct Answer: D
Rationale: Checking the insertion site is priority. Sneezing increases intra-abdominal pressure and increases the risk for clot disruption and bleeding from the femoral artery. Pedal pulses, vital signs, and urticaria are secondary concerns.
At 0745 hours, the nurse is informed by the HCP that a cardiac catheterization is to be completed on the client at 1400 hours. Which intervention should be the nurse’s priority?
- A. Place the client on NPO (nothing per mouth) status.
- B. Teach the client about the cardiac catheterization.
- C. Start an intravenous (IV) infusion of 0.9% NaCl.
- D. Witness the client’s signature on the consent form.
Correct Answer: A
Rationale: A cardiac catheterization is an invasive procedure requiring the client to lie still in a supine position. The client is usually sedated with medication, such as midazolam, during the procedure. To avoid aspiration, the client should be NPO 6 to 12 hours prior to the procedure, making this the priority at 0745 for a 1400 procedure.