Nokea
The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse?
- A. Muffled heart sounds.
- B. Nondistended jugular veins.
- C. Bounding peripheral pulses.
- D. Pericardial friction rub.
Correct Answer: A
Rationale: Muffled heart sounds (A) suggest cardiac tamponade, a life-threatening complication requiring immediate attention. Non-distended JVD (B) is normal, bounding pulses (C) are unrelated, and friction rub (D) is expected.
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The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?
- A. The client with three (3) unifocal PVCs in one (1) minute.
- B. The client diagnosed with coronary artery disease who wants to ambulate.
- C. The client diagnosed with mitral valve prolapse with an audible S3.
- D. The client diagnosed with pericarditis who is in normal sinus rhythm.
Correct Answer: C
Rationale: An S3 in mitral valve prolapse (C) suggests heart failure, requiring immediate assessment. Unifocal PVCs (A) are less urgent, ambulation (B) is routine, and normal rhythm in pericarditis (D) is stable.
The client shows ventricular fibrillation on the telemetry at the nurse’s station. Which action should the telemetry nurse implement first?
- A. Administer epinephrine IVP.
- B. Prepare to defibrillate the client.
- C. Call a STAT code.
- D. Start cardiopulmonary resuscitation (CPR).
Correct Answer: C
Rationale: Ventricular fibrillation is a code situation. Calling a STAT code (C) initiates the response team. Epinephrine (A), defibrillation (B), and CPR (D) follow code activation.
The client comes to the emergency department saying, 'I am having a heart attack.' Which question is most pertinent when assessing the client?
- A. Can you describe your chest pain?'
- B. What were you doing when the pain started?'
- C. Did you have a high-fat meal today?'
- D. Does the pain get worse when you lie down?'
Correct Answer: A
Rationale: Describing chest pain (A) is most pertinent to differentiate cardiac from non-cardiac causes. Activity (B), diet (C), and positional pain (D) are secondary.
The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of 'decreased cardiac output related to inability of the heart to pump effectively' is written. Which short-term goal would be best for the client?
- A. The client will be able to ambulate in the hall by date of discharge.
- B. The client will have an audible S1 and S2 with no S3 heard by end of shift.
- C. The client will turn, cough, and deep breathe every two (2) hours.
- D. The client will have a SaO2 reading of 98% by day two (2) of care.
Correct Answer: B
Rationale: Absence of an S3 heart sound (B) indicates improved cardiac function, directly addressing decreased cardiac output. Ambulation (A) is long-term, turning/coughing (C) is an intervention, and SaO2 of 98% (D) is less specific to cardiac output.
The nurse is assisting with a synchronized cardioversion on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take?
- A. Wait until the machine discharges.
- B. Shout 'all clear' and don’t touch the bed.
- C. Make sure the client is all right.
- D. Increase the joules and redischarge.
Correct Answer: A
Rationale: A pause in synchronized cardioversion is normal as the machine syncs with the QRS complex; wait for discharge (A). 'All clear' (B) is for defibrillation, checking client (C) is premature, and increasing joules (D) is incorrect.