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The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?
- A. Administer sublingual nitroglycerin.
- B. Obtain a STAT electrocardiogram (ECG).
- C. Have the client sit down immediately.
- D. Assess the client's vital signs.
Correct Answer: C
Rationale: Activity-related chest pain suggests ischemia. Having the client sit (C) stops exertion, reducing oxygen demand. Nitroglycerin (A), ECG (B), and vital signs (D) follow.
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What is the priority problem in the client diagnosed with congestive heart failure?
- A. Fluid volume overload.
- B. Decreased cardiac output.
- C. Activity intolerance.
- D. Knowledge deficit.
Correct Answer: B
Rationale: Decreased cardiac output (B) is the primary problem in CHF, causing symptoms like fluid overload (A). Activity intolerance (C) and knowledge deficit (D) are secondary.
The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis?
- A. Have you had a sore throat in the last month?'
- B. Did you have rheumatic fever as a child?'
- C. Do you have a family history of carditis?'
- D. What over-the-counter (OTC) medications do you take?'
Correct Answer: B
Rationale: Rheumatic fever (B) is a major cause of carditis, especially in children, making it the most relevant question. Sore throat (A) is less specific, family history (C) is rare, and OTC meds (D) are unrelated.
The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure?
- A. Perform passive range-of-motion exercises.
- B. Assess the client's neurovascular status.
- C. Keep the client in high Fowler's position.
- D. Assess the gag reflex prior to feeding the client.
Correct Answer: B
Rationale: Post-catheterization, assessing neurovascular status (B) ensures no bleeding or vascular complications. ROM (A) is inappropriate, high Fowler’s (C) is not required, and gag reflex (D) is irrelevant.
Which preprocedure information should be taught to the female client having an exercise stress test in the morning?
- A. Wear open-toed shoes to the stress test.
- B. Inform the client not to wear a bra.
- C. Do not eat anything for four (4) hours.
- D. Take the beta blocker one (1) hour before the test.
Correct Answer: C
Rationale: Fasting for 4 hours (C) prevents nausea and ensures accurate stress test results. Open-toed shoes (A) are unsafe, bras (B) are allowed, and beta blockers (D) may be held to avoid blunting heart rate response.
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.