Nokea
The client is three (3) hours post-myocardial infarction. Which data would warrant immediate intervention by the nurse?
- A. Bilateral peripheral pulses 2+.
- B. The pulse oximeter reading is 96%.
- C. The urine output is 240 mL in the last four (4) hours.
- D. Cool, clammy, diaphoretic skin.
Correct Answer: D
Rationale: Cool, clammy, diaphoretic skin (D) indicates cardiogenic shock or sympathetic response, requiring immediate intervention. Pulses (A), SpO2 (B), and urine output (C) are normal.
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The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first?
- A. Medicate the client with intravenous morphine.
- B. Assess the client's chest dressing and vital signs.
- C. Encourage the client to turn from side to side.
- D. Check the client's telemetry monitor.
Correct Answer: B
Rationale: Chest pain post-CABG may indicate complications. Assessing the dressing and vital signs (B) identifies bleeding or instability. Morphine (A), repositioning (C), and telemetry (D) follow.
The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication?
- A. The client's apical pulse is 64.
- B. The client's calcium level is elevated.
- C. The client's telemetry shows occasional PVCs.
- D. The client's blood pressure is 90/58.
Correct Answer: D
Rationale: Hypotension (BP 90/58, D) contraindicates calcium channel blockers, which lower BP further. Pulse 64 (A), elevated calcium (B), and PVCs (C) are not contraindications.
The client with coronary artery disease is prescribed transdermal nitroglycerin, a coronary vasodilator. Which behavior indicates the client understands the discharge teaching concerning this medication?
- A. The client places the medication under the tongue.
- B. The client removes the old patch before placing the new.
- C. The client applies the patch to a hairy area.
- D. The client changes the patch every 36 hours.
Correct Answer: B
Rationale: Removing the old patch (B) ensures proper dosing and prevents overdose. Sublingual (A) is incorrect, hairy areas (C) reduce adhesion, and patches are changed every 24 hours (D).
The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply.
- A. Start cardiopulmonary resuscitation.
- B. Prepare to administer the antidysrhythmic adenosine IVP.
- C. Prepare to defibrillate the client.
- D. Bring the crash cart to the bedside.
- E. Prepare to administer the antidysrhythmic amiodarone IVP.
Correct Answer: A,C,D,E
Rationale: Ventricular fibrillation requires CPR (A), defibrillation (C), crash cart (D), and amiodarone (E). Adenosine (B) is for SVT.
The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor?
- A. The client admitted for diagnostic tests to rule out valvular heart disease.
- B. The client three (3) days post-myocardial infarction being discharged tomorrow.
- C. The client exhibiting supraventricular tachycardia (SVT) on telemetry.
- D. The client diagnosed with atrial fibrillation who has an INR of five (5).
Correct Answer: A
Rationale: Diagnostic testing for valvular disease (A) is stable, suitable for a new graduate. Post-MI (B), SVT (C), and high INR (D) require experienced care.