Nokea
The client comes to the emergency department saying, 'I am having a heart attack.' Which question is most pertinent when assessing the client?
- A. Can you describe your chest pain?'
- B. What were you doing when the pain started?'
- C. Did you have a high-fat meal today?'
- D. Does the pain get worse when you lie down?'
Correct Answer: A
Rationale: Describing chest pain (A) is most pertinent to differentiate cardiac from non-cardiac causes. Activity (B), diet (C), and positional pain (D) are secondary.
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The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client?
- A. Social worker.
- B. Physical therapy.
- C. Cardiac rehabilitation.
- D. Occupational therapy.
Correct Answer: C
Rationale: Cardiac rehabilitation (C) promotes recovery through exercise and education post-MI. Social work (A), physical therapy (B), and occupational therapy (D) are less specific.
The home health nurse is assigned a client diagnosed with heart failure. Which should the nurse implement? Select all that apply.
- A. Request a dietary consult for a sodium-restricted diet.
- B. Instruct the client to elevate the feet during the day.
- C. Teach the client to weigh every morning wearing the same type of clothing.
- D. Assess for edema in dependent areas of the body.
- E. Encourage the client to drink at least 3,000 mL of fluid per day.
- F. Have the client repeat back instructions to the nurse.
Correct Answer: A,B,C,D,F
Rationale: Sodium restriction (A), elevating feet (B), daily weights (C), edema assessment (D), and teach-back (F) manage CHF. 3,000 mL fluid (E) risks overload.
The client with coronary artery disease asks the nurse, 'Why do I get chest pain?' Which statement would be the most appropriate response by the nurse?
- A. Chest pain is caused by decreased oxygen to the heart muscle.'
- B. There is ischemia to the myocardium as a result of hypoxemia.'
- C. The heart muscle is unable to pump effectively to perfuse the body.'
- D. Chest pain occurs when the lungs cannot adequately oxygenate the blood.'
Correct Answer: A
Rationale: Chest pain in CAD is due to decreased oxygen to the heart muscle (A), a clear explanation. Ischemia/hypoxemia (B) is technical, pumping (C) relates to heart failure, and lungs (D) are incorrect.
The nurse is assisting with a synchronized cardioversion on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take?
- A. Wait until the machine discharges.
- B. Shout 'all clear' and don’t touch the bed.
- C. Make sure the client is all right.
- D. Increase the joules and redischarge.
Correct Answer: A
Rationale: A pause in synchronized cardioversion is normal as the machine syncs with the QRS complex; wait for discharge (A). 'All clear' (B) is for defibrillation, checking client (C) is premature, and increasing joules (D) is incorrect.
The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first?
- A. Administer oxygen via nasal cannula.
- B. Evaluate the client's urinary output.
- C. Assess the client for cardiac complications.
- D. Encourage the client to use the incentive spirometer.
Correct Answer: C
Rationale: Increased pain in pericarditis may indicate complications like tamponade. Assessing for cardiac complications (C) is the priority. Oxygen (A), urinary output (B), and spirometry (D) are secondary.