Nokea
The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client?
- A. Pulsus paradoxus.
- B. Complaints of fatigue and arthralgias.
- C. Petechiae and splinter hemorrhages.
- D. Increased chest pain with inspiration.
Correct Answer: D
Rationale: Pericarditis causes pleuritic chest pain, worse with inspiration (D), due to pericardial inflammation. Pulsus paradoxus (A) and rub are less common, fatigue/arthralgias (B) are nonspecific, and petechiae/hemorrhages (C) suggest endocarditis.
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Using the following cardiac structures, trace the normal stress in which blood circulates on the left side of the heart. Use all the options.
- A. Aorta
- B. Left ventricle
- C. Pulmonary veins
- D. Left atrium
- E. Mitral valve (correct sequence: 3, 4, 5, 2, 1)
Correct Answer: D
Rationale: Blood flows: pulmonary veins → left atrium → mitral valve → left ventricle → aorta.
The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first?
- A. Administer amiodarone, an antidysrhythmic, IVP.
- B. Prepare to defibrillate the client.
- C. Assess the client's apical pulse and blood pressure.
- D. Start basic cardiopulmonary resuscitation.
Correct Answer: C
Rationale: Ventricular tachycardia requires assessing pulse/BP (C) to determine if it’s pulseless (defibrillation, B) or stable (amiodarone, A). CPR (D) is for pulseless states.
The nurse is admitting a client diagnosed with coronary artery disease (CAD) and angina. Which concept is priority?
- A. Sleep, rest, activity.
- B. Comfort.
- C. Oxygenation.
- D. Perfusion.
Correct Answer: D
Rationale: CAD and angina impair perfusion (D), the priority concept, as ischemia causes symptoms. Sleep/rest (A), comfort (B), and oxygenation (C) are secondary.
The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?
- A. Call a code immediately.
- B. Assess the client for a pulse.
- C. Begin chest compressions.
- D. Continue to monitor the client.
Correct Answer: B
Rationale: Ventricular tachycardia requires assessing for a pulse (B) to determine if it’s pulseless (needing CPR, C) or stable (medication). Calling a code (A) or monitoring (D) depends on pulse status.
The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse?
- A. The client diagnosed with congestive heart failure who is being discharged in the morning.
- B. The client who is having frequent incontinent liquid bowel movements and vomiting.
- C. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62.
- D. The client who is complaining of chest pain on inspiration and a nonproductive cough.
Correct Answer: C
Rationale: Tachycardia, tachypnea, and hypotension (C) suggest instability, requiring experienced nursing care. Discharging CHF (A), incontinence/vomiting (B), and pleuritic pain (D) are less acute.