Nokea
The client is admitted with an ACS. Which should be the nurse’s priority assessment?
- A. Pain
- B. Blood pressure
- C. Heart rate
- D. Respiratory rate
Correct Answer: A
Rationale: The nurse’s priority assessment in ACS is the client’s pain; pain indicates that the heart is not receiving adequate oxygen and blood flow (perfusion). BP, HR, and RR are secondary as they stem from the lack of perfusion.
You may also like to solve these questions
The nurse is caring for the client following a coronary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse?
- A. Copious chest tube output; now none for 1 hour
- B. Current core temperature of 101.3°F (38.5°C)
- C. pH 7.32; Paco2 48; HCO3 28; Pao2 80
- D. Urine output 160 mL in the last 4 hours
Correct Answer: A
Rationale: A copiously draining chest tube that is no longer draining indicates an obstruction. It should be most concerning because there is an increased risk for cardiac tamponade or pleural effusion. Slight fever, compensated respiratory acidosis, and adequate urine output are less urgent.
The client is hospitalized for HF secondary to alcohol-induced cardiomyopathy. The client is started on milrinone and placed on a transplant waiting list. The client has been curt and verbally aggressive in expressing dissatisfaction with the medications, overall care, and the need for energy conservation. Which nursing interpretation of the client’s behavior is most appropriate?
- A. The client is denying the illness.
- B. The client is experiencing fear.
- C. Alcohol abuse is affecting behavior.
- D. A reaction to milrinone is affecting behavior.
Correct Answer: B
Rationale: A threatening situation (need for heart transplant) can produce fear. Fear and helplessness may cause the client to verbally attack health team members to maintain control. There’s no evidence of denial, alcohol’s neurological effects, or milrinone causing behavior changes.
The nurse assesses the client returning from a coronary angiogram in which the femoral artery approach was used. The client’s baseline BP during the procedure was 130/72 mm Hg, and the cardiac rhythm was sinus rhythm. Which finding should alert the nurse to a potential complication?
- A. BP 154/78 mm Hg
- B. Pedal pulses palpable at +1
- C. Left groin soft to palpation with 1 cm ecchymotic area
- D. Apical pulse 132 beats per minute (bpm) with an irregular-irregular rhythm
Correct Answer: D
Rationale: An apical pulse of 132 bpm with an irregular-irregular rhythm could indicate atrial fibrillation or a rhythm with premature beats. Dysrhythmias are a complication that can occur following coronary angiogram. Slight BP elevation, +1 pulses, and minor ecchymosis are less concerning without additional context.
The nurse receives a serum laboratory report for six different clients with admitting diagnoses of chest pain. Prioritize the order in which the nurse should address each client’s laboratory result.
- A. Troponin T 42 ng/mL (0.0-0.4 ng/mL)
- B. WBC 11,000/mm3
- C. Hgb 7.2 g/dL
- D. SCr 2.2 mg/dL
- E. K 2.2 mEq/L
- F. Total cholesterol 430 mg/dL
Correct Answer: A;E;C;D;F;B
Rationale: The nurse should prioritize: A) Elevated troponin indicates MI, requiring immediate action; E) Low potassium can cause dysrhythmias; C) Low hemoglobin contributes to ischemia; D) Elevated creatinine suggests renal impairment; F) High cholesterol is a long-term risk; B) Normal WBC is least urgent.
The RN and the NA are caring for four clients, all in need of immediate attention. The NA is a senior nursing student who has been giving medications and performing procedures on clients as a student nurse. The unit charge nurse determines that care is appropriate when the RN working with the NA delegates which actions? Select all that apply.
- A. Give acetaminophen to the client with a high temperature.
- B. Take vital signs on the client newly admitted with heart failure.
- C. Discuss the pacemaker discharge handout so this client can go home.
- D. Change this client’s chest tube dressing; it got wet with drinking water.
- E. Provide a sponge bath for the client with the increased temperature.
Correct Answer: B;E
Rationale: The RN delegates appropriately when having the NA: B) Take vital signs; E) Perform a sponge bath. Administering medication (A), teaching (C), and changing chest tube dressings (D) are outside the NA’s scope of practice.