Nokea
The client is on nitroglycerin and reports chest pain. What is the nurse's priority action?
- A. Administer nitroglycerin as ordered.
- B. Administer morphine as ordered.
- C. Administer aspirin as ordered.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: The correct answer is D: Notify the healthcare provider immediately. When a client on nitroglycerin reports chest pain, it could indicate a worsening condition or potential myocardial infarction. The nurse's priority is to notify the healthcare provider promptly for further assessment and intervention. Administering nitroglycerin (choice A) may not address the underlying cause of the chest pain. Administering morphine (choice B) may mask symptoms and delay appropriate treatment. Administering aspirin (choice C) is important in chest pain management but does not take priority over notifying the healthcare provider for further evaluation and guidance.
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Which condition involves the tearing of the aorta, leading to severe pain and internal bleeding?
- A. Aortic dissection
- B. Aneurysm
- C. Stroke
- D. Myocardial infarction
Correct Answer: A
Rationale: The correct answer is A: Aortic dissection. This condition involves a tear in the inner layer of the aorta, leading to severe pain and internal bleeding. The tearing causes blood to flow between the layers of the aortic wall, which can be life-threatening. Aneurysm (B) is the abnormal bulging of a weakened blood vessel, not necessarily involving tearing. Stroke (C) is a brain-related condition, not related to the aorta. Myocardial infarction (D) is a heart attack due to blockage of blood flow to the heart, not directly involving the aorta.
A patient who underwent a percutaneous, transluminal coronary angioplasty four weeks ago has a subsequent ejection fraction of 30%. The patient returns for a follow-up visit. Examination reveals lungs that are clear on auscultation and slight pedal edema. The patient's medications are digoxin (Lanoxin), furosemide (Lasix), enalapril maleate (Vasotec), and aspirin. The patient reports a 5 lb (2.27 kg) weight gain over the past two days. The cardiac-vascular nurse's initial action is to:
- A. document the weight and reassess the patient at the next session.
- B. inquire about the patient's medication compliance.
- C. notify the patient's physician.
- D. review the patient's most recent nuclear scan.
Correct Answer: B
Rationale: Weight gain and pedal edema suggest fluid retention, so assessing medication compliance is essential.
In auscultating over a peripheral artery, what sound would suggest obstruction of the artery?
- A. Dullness
- B. Tympany
- C. Bruit
- D. Vibrations
Correct Answer: C
Rationale: A bruit is an abnormal sound heard over an artery due to turbulent blood flow, often indicating partial obstruction.
At 9:00 pm, you admit a 63-year-old with a diagnosis of acute myocardial infarction (AMI) to the ED. The physician is considering the use of fibrinolytic therapy with tissue plasminogen activator (tPA, alteplase). Which information is most important to communicate to the physician?
- A. The patient was treated with alteplase about 8 months ago.
- B. The patient takes famotidine (Pepcid) for esophageal reflux.
- C. The patient has T wave inversions on the 12-lead ECG.
- D. The patient has had continuous chest pain since 1:00 pM.
Correct Answer: D
Rationale: Continuous chest pain indicates ongoing ischemia, making the patient a candidate for fibrinolytic therapy within the therapeutic window.
What procedure is used to visualize the airways and diagnose lung disease?
- A. Bronchoscopy
- B. Thoracentesis
- C. Pulmonary function test
- D. Chest X-ray
Correct Answer: A
Rationale: The correct answer is A: Bronchoscopy. Bronchoscopy is a procedure where a thin, flexible tube with a camera is inserted into the airways to visualize and diagnose lung diseases directly. It allows for direct visualization of the airways, collection of samples for biopsy, and removal of obstructions. Thoracentesis (B) is a procedure to remove fluid from the pleural space, not for visualizing airways. Pulmonary function test (C) measures lung function but doesn't directly visualize airways. Chest X-ray (D) provides an image of the lungs but doesn't allow for direct visualization or diagnosis of airway diseases.