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The client diagnosed with an ST elevation myocardial infarction (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which should the nurse implement first?
- A. Notify the health care provider (HCP).
- B. Assess what the client ate at the last meal.
- C. Request a STAT 12 lead electrocardiogram.
- D. Administer furosemide IVP.
Correct Answer: A
Rationale: Edema and crackles post-STEMI suggest heart failure; notifying the HCP (A) ensures timely intervention. Diet (B), ECG (C), and furosemide (D) follow HCP orders.
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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.
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.
The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply.
- A. Monitor vital signs every 15 minutes for the first hour.
- B. Assess the client's heart and lung sounds.
- C. Record the amount of fluid removed as output.
- D. Evaluate the client's cardiac rhythm.
- E. Keep the client in the supine position.
Correct Answer: A,B,C,D
Rationale: Post-pericardiocentesis, monitor vital signs (A), heart/lung sounds (B), fluid output (C), and rhythm (D) to detect complications. Supine position (E) is not required; semi-Fowler’s is preferred.
The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse?
- A. Muffled heart sounds.
- B. Nondistended jugular veins.
- C. Bounding peripheral pulses.
- D. Pericardial friction rub.
Correct Answer: A
Rationale: Muffled heart sounds (A) suggest cardiac tamponade, a life-threatening complication requiring immediate attention. Non-distended JVD (B) is normal, bounding pulses (C) are unrelated, and friction rub (D) is expected.
The client is admitted to the emergency department, and the nurse suspects a cardiac problem. Which assessment interventions should the nurse implement? Select all that apply.
- A. Obtain a midstream urine specimen.
- B. Attach the telemetry monitor to the client.
- C. Start a saline lock in the right arm.
- D. Draw a basal metabolic panel (BMP).
- E. Request an order for a STAT 12-lead ECG.
Correct Answer: B,C,E
Rationale: Telemetry (B), saline lock (C), and STAT ECG (E) assess cardiac status. Urine specimen (A) and BMP (D) are not priority for suspected cardiac issues.