Nokea
The client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this client?
- A. Prepare for a pericardiocentesis.
- B. Request STAT cardiac enzymes.
- C. Perform a 12-lead electrocardiogram.
- D. Assess the client's heart and lung sounds.
Correct Answer: A
Rationale: Cardiac tamponade requires pericardiocentesis (A) to remove fluid. Enzymes (B), ECG (C), and heart/lung sounds (D) are supportive but not primary.
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Which client problem has priority for the client with a cardiac dysrhythmia?
- A. Alteration in comfort.
- B. Decreased cardiac output.
- C. Impaired gas exchange.
- D. Activity intolerance.
Correct Answer: B
Rationale: Dysrhythmias primarily reduce cardiac output (B), impacting perfusion, making it the priority. Comfort (A), gas exchange (C), and activity (D) are secondary.
The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?
- A. Notify the health-care provider.
- B. Document that the pericarditis has resolved.
- C. Ask the client to lean forward and listen again.
- D. Prepare to insert a unilateral chest tube.
Correct Answer: C
Rationale: Leaning forward (C) enhances auscultation of a pericardial friction rub, which may be positional. Notifying HCP (A), documenting resolution (B), or chest tube (D) are premature or unrelated.
The client is three (3) hours post-myocardial infarction. Which data would warrant immediate intervention by the nurse?
- A. Bilateral peripheral pulses 2+.
- B. The pulse oximeter reading is 96%.
- C. The urine output is 240 mL in the last four (4) hours.
- D. Cool, clammy, diaphoretic skin.
Correct Answer: D
Rationale: Cool, clammy, diaphoretic skin (D) indicates cardiogenic shock or sympathetic response, requiring immediate intervention. Pulses (A), SpO2 (B), and urine output (C) are normal.
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
- A. Assist the client to go down to the smoking area for a cigarette.
- B. Transport the client to the intensive care unit (ICU) via a stretcher.
- C. Provide the client going home discharge-teaching instructions.
- D. Help position the client who is having a portable x-ray done.
Correct Answer: D
Rationale: Positioning for an x-ray (D) is within the UAP’s scope and safe. Smoking (A) is inappropriate, ICU transport (B) requires nursing judgment, and discharge teaching (C) is a nursing responsibility.
The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first?
- A. Medicate the client with intravenous morphine.
- B. Assess the client's chest dressing and vital signs.
- C. Encourage the client to turn from side to side.
- D. Check the client's telemetry monitor.
Correct Answer: B
Rationale: Chest pain post-CABG may indicate complications. Assessing the dressing and vital signs (B) identifies bleeding or instability. Morphine (A), repositioning (C), and telemetry (D) follow.