Nokea
The client is admitted with acute infective endocarditis (IE). Which assessment findings should the nurse associate with IE? Select all that apply.
- A. Skin petechiae
- B. Crackles in lung bases
- C. Peripheral edema
- D. Murmur
- E. Arthralgia
- F. Hemangioma
Correct Answer: A;B;C;D;E
Rationale: The nurse should associate: A) Skin petechiae from microembolism; B) Crackles from HF secondary to IE; C) Peripheral edema from HF; D) Murmur from valve incompetence; E) Arthralgia from microembolism. Hemangioma is not associated with IE.
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The nurse increases activity for the client with an admitting diagnosis of ACS. Which client finding best supports that the client is not tolerating the activity?
- A. Pulse rate increased by 15 beats per minute during activity
- B. BP 130/86 mm Hg before activity; 108/66 mm Hg during activity
- C. Increased dyspnea and diaphoresis relieved when sitting in a chair
- D. A mean arterial pressure (MAP) of 80 following activity
Correct Answer: B
Rationale: A drop in BP of 20 mm Hg from the baseline indicates that the client’s heart is unable to adapt to the increased energy and oxygen demands of the activity. The client is not tolerating the activity; the length of time or the intensity should be reduced. A modest pulse increase, relieved symptoms, and normal MAP are less concerning.
The nurse completes teaching the client about CAD and self-care at home. The nurse determines that teaching is effective when the client makes which statements? Select all that apply.
- A. “If I have chest pain, I should contact my physician immediately.”
- B. “I should carry my nitroglycerin in my front pants pocket so it is handy.”
- C. “If I have chest pain, I stop activity and chew a nitroglycerin tablet.”
- D. “I should always take three nitroglycerin tablets, 5 minutes apart.”
- E. “I plan to avoid being around people when they are smoking.”
- F. “I plan on walking on most days of the week for at least 30 minutes.”
Correct Answer: E;F
Rationale: Teaching is effective when the client states: E) Avoiding passive smoke to prevent vasoconstriction; F) Walking 30 minutes most days as recommended by the American Heart Association. Contacting the physician immediately is incorrect (call 911), pants pockets are not ideal for nitroglycerin storage, nitroglycerin is taken sublingually not chewed, and three tablets are not always needed.
The nurse completes teaching the client with a newly inserted ICD. Which statement, if made by the client, indicates that further teaching is needed?
- A. “The ICD will give me a shock if my heart goes into ventricular fibrillation again.”
- B. “When I feel the first shock, my family should start CPR immediately and call 911.”
- C. “I’m afraid of my first shock; my friend stated his shock felt like a blow to the chest.”
- D. “Some states do not allow driving until there is a 6-month discharge-free period.”
Correct Answer: B
Rationale: CPR should only be initiated if the client is unresponsive and pulseless. EMS should be called if there is more than one shock. This statement indicates further teaching is needed. The other statements are correct regarding ICD function, shock sensation, and driving restrictions.
The nurse, caring for the client following an anterior MI, obtains the assessment findings illustrated. Based on these findings, the nurse should immediately notify the HCP and plan which intervention?
- A. Administer an IV fluid bolus of 0.9% NaCl; the client is in right heart failure.
- B. Initiate an IV infusion of dopamine; the client is in cardiogenic shock.
- C. Prepare the client for pericardiocentesis; the findings support cardiac tamponade.
- D. Notify radiology for a STAT chest x-ray to rule out pulmonary embolism (PE).
Correct Answer: B
Rationale: Complications of an anterior MI are left ventricular failure, reduced cardiac output, and cardiogenic shock. The client’s MAP is 55, with hypotension, tachycardia, tachypnea, and low urine output, indicating cardiogenic shock. Dopamine is administered to increase cardiac output. Right HF, tamponade, and PE are less likely based on the findings.
The client states to the clinic nurse, “I had pain in the left calf for a few days earlier in the week, but I am pain free now.” The nurse’s assessment findings include: dorsalis pedis pulses palpable, no pain upon dorsiflexion bilaterally, a few visible varicose veins in each leg, and slight swelling in only the left leg. Which is the nurse’s best action?
- A. Ask if the client has been walking more lately.
- B. Inform the HCP of the assessment findings.
- C. Ask if the client has considered taking a baby aspirin daily.
- D. Explain to the client that there are no significant findings.
Correct Answer: B
Rationale: The nurse should inform the HCP about the assessment findings. A possible DVT is taken seriously because it can lead to PE. Unilateral swelling of one leg is a classic symptom of DVT. Additional questions, aspirin advice, or dismissing findings are inappropriate without further evaluation.