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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.
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The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement?
- A. Perform isometric exercises daily.
- B. Walk for 15 minutes three (3) times a week.
- C. Do not walk outside if it is less than 40°F.
- D. Wear open-toed shoes when ambulating.
Correct Answer: B
Rationale: Walking 15 minutes 3 times a week (B) is a safe, aerobic exercise for CAD. Isometric exercises (A) increase BP, cold weather (C) is a precaution, and open-toed shoes (D) are irrelevant.
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 client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented?
- A. Check the client for peripheral edema and make sure the client takes a diuretic early in the day.
- B. Monitor the client's potassium level and assess the client's intake of bananas and orange juice.
- C. Determine if the client has gained weight and instruct the client to keep the legs elevated.
- D. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.
Correct Answer: B
Rationale: Leg cramps in CHF may indicate hypokalemia from diuretics. Monitoring potassium and assessing potassium-rich food intake (B) is appropriate. Edema/diuretic timing (A), weight/elevation (C), and ambulation/stretching (D) are less directly related.
The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first?
- A. Administer oxygen via nasal cannula.
- B. Evaluate the client's urinary output.
- C. Assess the client for cardiac complications.
- D. Encourage the client to use the incentive spirometer.
Correct Answer: C
Rationale: Increased pain in pericarditis may indicate complications like tamponade. Assessing for cardiac complications (C) is the priority. Oxygen (A), urinary output (B), and spirometry (D) are secondary.
Which meal would indicate the client understands the discharge teaching concerning the recommended diet for coronary artery disease?
- A. Baked fish, steamed broccoli, and garden salad.
- B. Enchilada dinner with fried rice and refried beans.
- C. Tuna salad sandwich on white bread and whole milk.
- D. Fried chicken, mashed potatoes, and gravy.
Correct Answer: A
Rationale: Baked fish, steamed broccoli, and salad (A) are low-fat and heart-healthy, aligning with CAD diet teaching. Enchiladas (B), tuna with whole milk (C), and fried chicken (D) are high in fat/sodium.