Nokea
The client diagnosed with a myocardial infarction asks the nurse, 'Why do I have to rest and take it easy? My chest doesn’t hurt anymore.' Which statement would be the nurse’s best response?
- A. Your heart is damaged and needs about four (4) to six (6) weeks to heal.'
- B. There is necrotic myocardial tissue that puts you at risk for dysrhythmias.'
- C. Your doctor has ordered bedrest. Therefore, you must stay in the bed.'
- D. Just because your chest doesn’t hurt anymore doesn’t mean you are out of danger.'
Correct Answer: A
Rationale: Explaining that the heart needs 4–6 weeks to heal (A) is accurate and understandable. Necrosis/dysrhythmias (B) is technical, doctor’s orders (C) dismiss patient autonomy, and danger (D) is vague.
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The client shows ventricular fibrillation on the telemetry at the nurse’s station. Which action should the telemetry nurse implement first?
- A. Administer epinephrine IVP.
- B. Prepare to defibrillate the client.
- C. Call a STAT code.
- D. Start cardiopulmonary resuscitation (CPR).
Correct Answer: C
Rationale: Ventricular fibrillation is a code situation. Calling a STAT code (C) initiates the response team. Epinephrine (A), defibrillation (B), and CPR (D) follow code activation.
Which population is at a higher risk for dying from a myocardial infarction?
- A. Caucasian males.
- B. Hispanic females.
- C. Asian males.
- D. African American females.
Correct Answer: D
Rationale: African American females (D) have higher MI mortality rates due to increased prevalence of risk factors like hypertension and diabetes, and disparities in healthcare access. Caucasian males (A), Hispanic females (B), and Asian males (C) have lower relative risk.
Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet?
- A. I will not eat more than six (6) eggs a week.'
- B. I should bake or grill any meats I eat.'
- C. I will drink eight (8) ounces of whole milk a day.'
- D. I should not eat any type of pork products.'
Correct Answer: B
Rationale: Baking or grilling meats (B) reduces fat, aligning with a low-fat CAD diet. Six eggs (A) are excessive, whole milk (C) is high-fat, and avoiding pork (D) is overly restrictive.
Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation?
- A. Defibrillate the client at 50, 100, and 200 joules.
- B. Do not remove the oxygen source during defibrillation.
- C. Place petroleum jelly on the defibrillator pads.
- D. Shout 'all clear' prior to defibrillating the client.
Correct Answer: D
Rationale: Shouting 'all clear' (D) ensures safety before defibrillation. Energy levels (A) are 200–360 joules, oxygen (B) is removed to prevent fire, and petroleum jelly (C) is not used.
The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?
- A. The client with three (3) unifocal PVCs in one (1) minute.
- B. The client diagnosed with coronary artery disease who wants to ambulate.
- C. The client diagnosed with mitral valve prolapse with an audible S3.
- D. The client diagnosed with pericarditis who is in normal sinus rhythm.
Correct Answer: C
Rationale: An S3 in mitral valve prolapse (C) suggests heart failure, requiring immediate assessment. Unifocal PVCs (A) are less urgent, ambulation (B) is routine, and normal rhythm in pericarditis (D) is stable.