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The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented?
- A. Administer a thrombolytic medication.
- B. Assess the client's cardiovascular status.
- C. Prepare for insertion of a pacemaker.
- D. Obtain a permit for synchronized cardioversion.
Correct Answer: C
Rationale: Symptomatic bradycardia (syncope, hypotension) often requires a pacemaker (C). Thrombolytics (A) are for MI, assessment (B) is ongoing, and cardioversion (D) is for tachydysrhythmias.
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The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement?
- A. Instruct the client to keep a diary of activity, especially when having chest pain.
- B. Discuss the need to remove the Holter monitor during a.m. care and showering.
- C. Explain that all medications should be withheld while wearing a Holter monitor.
- D. Teach the client the importance of decreasing activity while wearing the monitor.
Correct Answer: A
Rationale: A diary (A) correlates symptoms with ECG changes on the Holter monitor. Removal (B) is incorrect, medications (C) continue, and decreasing activity (D) is unnecessary.
The licensed practical nurse (LPN) is assisting the registered nurse (RN) in developing the nursing care plan for an older adult who has congestive heart failure. Which nursing diagnosis is most likely to be included?
- A. Deficient fluid volume
- B. Impaired verbal communication
- C. Chronic pain
- D. Activity intolerance
Correct Answer: D
Rationale: Activity intolerance is common in congestive heart failure due to reduced cardiac output and fatigue. Fluid volume excess, not deficit, is typical, and communication or pain are less likely.
The nurse identifies the concept of perfusion for a client diagnosed with congestive heart failure. Which assessment data support this concept?
- A. The client has a large abdomen and a positive tympanic wave.
- B. The client has paroxysmal nocturnal dyspnea.
- C. The client has 2+ glucose in the urine.
- D. The client has a comorbid condition of myocardial infarction.
Correct Answer: B
Rationale: PND (B) indicates fluid overload in CHF, supporting impaired perfusion. Large abdomen (A) suggests ascites, glucosuria (C) is diabetes-related, and MI (D) is a cause, not a symptom.
During the admission interview, a client who is admitted for a cardiac catheterization says, 'Every time I eat shrimp I get a rash.' What action is essential for the nurse to take at this time?
- A. Notify the physician.
- B. Ask the client if she gets a rash from any other foods.
- C. Instruct the dietary department not to give the client shrimp.
- D. Teach the client the dangers of eating shrimp and other shellfish.
Correct Answer: A
Rationale: A shrimp allergy may indicate an iodine allergy, as shellfish contain iodine, which is also present in the dye used for cardiac catheterization. Notifying the physician is essential to assess the risk and consider alternative dyes or premedication. Asking about other foods, instructing the dietary department, or teaching about shellfish dangers are secondary actions.
The nurse is transcribing the doctor’s orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement?
- A. Discuss the order with the health-care provider.
- B. Take the client’s apical pulse rate before administering.
- C. Check the client’s potassium level before giving the medication.
- D. Determine if a digoxin level has been drawn.
Correct Answer: A
Rationale: Lanoxin (digoxin) 2.5 mg (A) exceeds the safe dose (0.125–0.25 mg daily), requiring HCP clarification. Pulse (B), potassium (C), and digoxin level (D) are routine but secondary to dose error.