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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.
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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.
Which meal would indicate the client understands the discharge teaching concerning the recommended diet for coronary artery disease?
- A. Baked fish, steamed broccoli, and garden salad.
- B. Enchilada dinner with fried rice and refried beans.
- C. Tuna salad sandwich on white bread and whole milk.
- D. Fried chicken, mashed potatoes, and gravy.
Correct Answer: A
Rationale: Baked fish, steamed broccoli, and salad (A) are low-fat and heart-healthy, aligning with CAD diet teaching. Enchiladas (B), tuna with whole milk (C), and fried chicken (D) are high in fat/sodium.
The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective?
- A. The client's peripheral pitting edema has gone from 3+ to 4+.
- B. The client is able to take the radial pulse accurately.
- C. The client is able to perform ADLs without dyspnea.
- D. The client has minimal jugular vein distention.
Correct Answer: C,D
Rationale: Effective CHF treatment reduces fluid overload, allowing ADLs without dyspnea (C) and minimal JVD (D). Increased edema (A) indicates worsening, and pulse-taking (B) is a skill, not a treatment outcome.
Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency?
- A. A loud S1, S2 split, and a mitral opening snap.
- B. A holosystolic murmur heard best at the cardiac apex.
- C. A midsystolic ejection click or murmur heard at the base.
- D. A high-pitched sound heard at the third left intercostal space.
Correct Answer: B
Rationale: Mitral insufficiency (regurgitation) causes a holosystolic murmur at the apex (B) due to backflow. S1/S2 snap (A) is mitral stenosis, ejection click (C) is aortic/pulmonic, and high-pitched sound (D) is nonspecific.
Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?
- A. Pulmonary embolus (PE).
- B. Cerebrovascular accident.
- C. Hemoptysis.
- D. Deep vein thrombosis.
Correct Answer: B
Rationale: Mitral valve vegetations can embolize to the brain, causing a stroke (B). PE (A) is right-sided, hemoptysis (C) is not typical, and DVT (D) is unrelated to embolization.