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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.
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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.
The client diagnosed with a myocardial infarction (MI) is being discharged. Which discharge instruction(s) should the nurse teach the client?
- A. Call the health care provider (HCP) if any chest pain happens.
- B. Discuss when the client can resume sexual activity.
- C. Explain the pharmacology of nitroglycerin tablets.
- D. Encourage the client to sleep with the head of the bed elevated.
Correct Answer: A,B,C
Rationale: Instructing to call HCP for chest pain (A), discussing sexual activity (B), and explaining nitroglycerin (C) ensure safety and recovery. HOB elevation (D) is for CHF, not MI.
The client is in complete heart block. Which intervention should the nurse implement first?
- A. Prepare to insert a pacemaker.
- B. Administer atropine, an antidysrhythmic.
- C. Obtain a STAT electrocardiogram (ECG).
- D. Notify the health-care provider.
Correct Answer: B
Rationale: Complete heart block may respond to atropine (B) to increase heart rate acutely. Pacemaker (A), ECG (C), and HCP notification (D) follow if atropine fails.
The 45-year-old male client diagnosed with essential hypertension has decided not to take his medications. The client's BP is 178/94, indicating a perfusion issue. Which question should the nurse ask the client first?
- A. Do you have the money to buy your medication?'
- B. Does the medication give unwanted side effects?'
- C. Did you quit taking the medications because you don’t feel bad?'
- D. Can you tell me why you stopped taking the medication?'
Correct Answer: D
Rationale: Asking why the client stopped (D) is open-ended, identifying barriers like side effects (B) or asymptomatic disease (C). Financial issues (A) are secondary.
The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented?
- A. Check the client for peripheral edema and make sure the client takes a diuretic early in the day.
- B. Monitor the client's potassium level and assess the client's intake of bananas and orange juice.
- C. Determine if the client has gained weight and instruct the client to keep the legs elevated.
- D. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.
Correct Answer: B
Rationale: Leg cramps in CHF may indicate hypokalemia from diuretics. Monitoring potassium and assessing potassium-rich food intake (B) is appropriate. Edema/diuretic timing (A), weight/elevation (C), and ambulation/stretching (D) are less directly related.