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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.
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The client with coronary artery disease asks the nurse, 'Why do I get chest pain?' Which statement would be the most appropriate response by the nurse?
- A. Chest pain is caused by decreased oxygen to the heart muscle.'
- B. There is ischemia to the myocardium as a result of hypoxemia.'
- C. The heart muscle is unable to pump effectively to perfuse the body.'
- D. Chest pain occurs when the lungs cannot adequately oxygenate the blood.'
Correct Answer: A
Rationale: Chest pain in CAD is due to decreased oxygen to the heart muscle (A), a clear explanation. Ischemia/hypoxemia (B) is technical, pumping (C) relates to heart failure, and lungs (D) are incorrect.
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 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.
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 intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?
- A. Notify the health-care provider immediately.
- B. Elevate the head of the client's bed.
- C. Document this as a normal and expected finding.
- D. Administer morphine intravenously.
Correct Answer: A
Rationale: An S3 heart sound post-MI (A) indicates heart failure, requiring HCP notification. Elevating HOB (B) is supportive, documenting as normal (C) is incorrect, and morphine (D) is for pain.