Nokea
The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the Post Anesthesia Care Unit nurse implement?
- A. Assess the client's chest tube output.
- B. Monitor the client's chest dressing.
- C. Evaluate the client's endotracheal (ET) lip line.
- D. Keep the client's affected leg straight.
Correct Answer: D
Rationale: Valvuloplasty is performed via femoral access, so keeping the leg straight (D) prevents bleeding. Chest tubes (A), dressings (B), and ET tubes (C) are not involved.
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The nurse is assisting with a synchronized cardioversion on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take?
- A. Wait until the machine discharges.
- B. Shout 'all clear' and don’t touch the bed.
- C. Make sure the client is all right.
- D. Increase the joules and redischarge.
Correct Answer: A
Rationale: A pause in synchronized cardioversion is normal as the machine syncs with the QRS complex; wait for discharge (A). 'All clear' (B) is for defibrillation, checking client (C) is premature, and increasing joules (D) is incorrect.
The client diagnosed with an ST elevation myocardial infarction (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which should the nurse implement first?
- A. Notify the health care provider (HCP).
- B. Assess what the client ate at the last meal.
- C. Request a STAT 12 lead electrocardiogram.
- D. Administer furosemide IVP.
Correct Answer: A
Rationale: Edema and crackles post-STEMI suggest heart failure; notifying the HCP (A) ensures timely intervention. Diet (B), ECG (C), and furosemide (D) follow HCP orders.
Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation?
- A. Defibrillate the client at 50, 100, and 200 joules.
- B. Do not remove the oxygen source during defibrillation.
- C. Place petroleum jelly on the defibrillator pads.
- D. Shout 'all clear' prior to defibrillating the client.
Correct Answer: D
Rationale: Shouting 'all clear' (D) ensures safety before defibrillation. Energy levels (A) are 200–360 joules, oxygen (B) is removed to prevent fire, and petroleum jelly (C) is not used.
The client with coronary artery disease asks the nurse, 'Why do I get chest pain?' Which statement would be the most appropriate response by the nurse?
- A. Chest pain is caused by decreased oxygen to the heart muscle.'
- B. There is ischemia to the myocardium as a result of hypoxemia.'
- C. The heart muscle is unable to pump effectively to perfuse the body.'
- D. Chest pain occurs when the lungs cannot adequately oxygenate the blood.'
Correct Answer: A
Rationale: Chest pain in CAD is due to decreased oxygen to the heart muscle (A), a clear explanation. Ischemia/hypoxemia (B) is technical, pumping (C) relates to heart failure, and lungs (D) are incorrect.
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.