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The client is being fitted for a Holter Monitor. What does the nurse tell the client in preparation for the test?
- A. The client should lie motionless for the test.
- B. The client can shower but cannot bathe.
- C. The test will take about 30 minutes.
- D. The client should record the time of any palpable events, such as palpitations.
Correct Answer: D
Rationale: The correct answer is D because the client should record the time of any palpable events, such as palpitations, during the Holter Monitor test to provide valuable information to healthcare providers. This step is crucial for correlating symptoms with the recorded heart activity. Choice A is incorrect because clients are encouraged to continue their normal activities during the test. Choice B is incorrect as clients can bathe while wearing the monitor. Choice C is incorrect as the Holter Monitor test typically lasts for 24-48 hours, not just 30 minutes.
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A toddler requires supplemental oxygen therapy for a cyanotic heart defect. In planning for home care, the nurse would discuss which of the following with the parents?
- A. The need to maintain the child on bedrest.
- B. Means of promoting mobility while meeting the need for supplemental oxygen.
- C. Symptoms of oxygen toxicity.
- D. How to draw blood for blood gases.
Correct Answer: B
Rationale: The correct answer is B because promoting mobility while meeting the need for supplemental oxygen is crucial for the toddler's overall well-being. This helps prevent complications such as pneumonia and promotes physical development. Maintaining the child on bedrest (A) is not recommended as it can lead to muscle weakness and other health issues. Discussing symptoms of oxygen toxicity (C) is important but not the priority in this scenario. Drawing blood for blood gases (D) should be performed by healthcare professionals, not parents.
The nurse prepares a patient for insertion of a pulmonary artery catheter. Preprocedural teaching for this client will include which of the following statements?
- A. The catheter will assist in directly monitoring your arterial pressure
- B. The catheter will provide information about your cardiac output
- C. The catheter will provide information about your left ventricular function
- D. The catheter will provide information about your cardiac index
Correct Answer: C
Rationale: A pulmonary artery catheter will provide information about the left ventricular function. The catheter does not directly determine the cardiac output or index.
When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that
- A. sudden cardiac death events rarely reoccur.
- B. additional diagnostic testing will be required.
- C. long-term anticoagulation therapy will be needed.
- D. limiting physical activity will prevent future SCD events.
Correct Answer: B
Rationale: The correct answer is B because after a sudden cardiac death (SCD) event without evidence of an acute myocardial infarction (AMI), additional diagnostic testing is needed to determine the underlying cause and assess the risk of recurrence. This testing may include cardiac imaging, electrophysiological studies, and genetic testing. By identifying the specific cause, healthcare providers can tailor treatment plans to prevent future SCD events.
A: This is incorrect because the risk of SCD recurrence can vary based on the underlying cause and individual patient factors.
C: Long-term anticoagulation therapy is not typically indicated for SCD without evidence of AMI unless there is a specific indication such as atrial fibrillation or a clotting disorder.
D: Limiting physical activity alone is not a comprehensive strategy for preventing future SCD events; individualized recommendations should be based on diagnostic findings.
A patient is admitted to your acute coronary care unit with the diagnosis of ACS. The nurse has seen ECG changes that are indicative of an anterior wall infarction and is observing the patient for signs/symptoms of complications. The nurse has noted the following vital sign trends: 1100-HR 92, RR 24, BP 140/88, Cardiac rhythm NSR 1115-HR 96, RR 26, BP 128/82, Cardiac rhythm NSR 1130-HR 104, RR 28, BP 102/68, Cardiac rhythm ST 1145-HR 120, RR 32, BP 80/52, Cardiac rhythm ST with frequent PVC's The nurse should be alert for which of the following complications? Choose all that apply.
- A. Syncope
- B. Pericarditis
- C. Cardiogenic shock
- D. Cardiac tamponade
Correct Answer: C
Rationale: The correct answer is C - Cardiogenic shock. In this scenario, the vital sign trends indicate a progressive decline in blood pressure (BP) along with an increasing heart rate (HR) and respiratory rate (RR), which are signs of hemodynamic instability. Cardiogenic shock is a serious complication of acute coronary syndrome (ACS) and occurs when the heart is unable to pump enough blood to meet the body's demands. The decreasing BP and increasing HR in this patient suggest a failing cardiac output, leading to inadequate tissue perfusion and subsequent shock. Syncope (choice A) is possible but less likely given the progressive decline in vital signs. Pericarditis (choice B) typically presents with chest pain and ECG changes different from those seen in this case. Cardiac tamponade (choice D) is characterized by Beck's triad (muffled heart sounds, hypotension, and jugular venous distention), which is not evident in the vital sign trends provided.
The client is on hydrochlorothiazide and digoxin. What effect can the nurse expect?
- A. Hydrochlorothiazide increases digoxin levels.
- B. Hydrochlorothiazide decreases digoxin levels.
- C. Hydrochlorothiazide decreases potassium, increasing the risk of digoxin toxicity.
- D. Digoxin can increase the effectiveness of hydrochlorothiazide.
Correct Answer: C
Rationale: Step-by-step rationale:
1. Hydrochlorothiazide is a diuretic that can cause hypokalemia.
2. Digoxin toxicity is more likely with low potassium levels.
3. Therefore, hydrochlorothiazide decreasing potassium levels can increase the risk of digoxin toxicity.
Summary:
A: Incorrect. Hydrochlorothiazide does not increase digoxin levels.
B: Incorrect. Hydrochlorothiazide does not decrease digoxin levels.
C: Correct. Hydrochlorothiazide can decrease potassium, increasing digoxin toxicity risk.
D: Incorrect. Digoxin does not increase the effectiveness of hydrochlorothiazide.