Nokea
The client who has pain while walking has an ankle-brachial index (ABI) test. Results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, which should be the nurse’s conclusion?
- A. The client likely has peripheral arterial disease (PAD).
- B. Ticlopidine hydrochloride should be prescribed.
- C. The client’s pain is most likely psychological in origin.
- D. Medical follow-up is needed to determine the cause of pain.
Correct Answer: D
Rationale: The client requires further medical consultation because the ABI (comparison of BP in ankle to the brachial BP) is normal in each leg (1.4 and 1.3; normal is 0.9-1.3). A ratio <0.9 indicates PAD. Ticlopidine is inappropriate, and psychological pain is not supported without further evidence.
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The nurse, caring for the client following an anterior MI, obtains the assessment findings illustrated. Based on these findings, the nurse should immediately notify the HCP and plan which intervention?
- A. Administer an IV fluid bolus of 0.9% NaCl; the client is in right heart failure.
- B. Initiate an IV infusion of dopamine; the client is in cardiogenic shock.
- C. Prepare the client for pericardiocentesis; the findings support cardiac tamponade.
- D. Notify radiology for a STAT chest x-ray to rule out pulmonary embolism (PE).
Correct Answer: B
Rationale: Complications of an anterior MI are left ventricular failure, reduced cardiac output, and cardiogenic shock. The client’s MAP is 55, with hypotension, tachycardia, tachypnea, and low urine output, indicating cardiogenic shock. Dopamine is administered to increase cardiac output. Right HF, tamponade, and PE are less likely based on the findings.
The nurse completes teaching the client about CAD and self-care at home. The nurse determines that teaching is effective when the client makes which statements? Select all that apply.
- A. “If I have chest pain, I should contact my physician immediately.”
- B. “I should carry my nitroglycerin in my front pants pocket so it is handy.”
- C. “If I have chest pain, I stop activity and chew a nitroglycerin tablet.”
- D. “I should always take three nitroglycerin tablets, 5 minutes apart.”
- E. “I plan to avoid being around people when they are smoking.”
- F. “I plan on walking on most days of the week for at least 30 minutes.”
Correct Answer: E;F
Rationale: Teaching is effective when the client states: E) Avoiding passive smoke to prevent vasoconstriction; F) Walking 30 minutes most days as recommended by the American Heart Association. Contacting the physician immediately is incorrect (call 911), pants pockets are not ideal for nitroglycerin storage, nitroglycerin is taken sublingually not chewed, and three tablets are not always needed.
The nurse completes teaching the client with a newly inserted ICD. Which statement, if made by the client, indicates that further teaching is needed?
- A. “The ICD will give me a shock if my heart goes into ventricular fibrillation again.”
- B. “When I feel the first shock, my family should start CPR immediately and call 911.”
- C. “I’m afraid of my first shock; my friend stated his shock felt like a blow to the chest.”
- D. “Some states do not allow driving until there is a 6-month discharge-free period.”
Correct Answer: B
Rationale: CPR should only be initiated if the client is unresponsive and pulseless. EMS should be called if there is more than one shock. This statement indicates further teaching is needed. The other statements are correct regarding ICD function, shock sensation, and driving restrictions.
The client is admitted with an ACS. Which should be the nurse’s priority assessment?
- A. Pain
- B. Blood pressure
- C. Heart rate
- D. Respiratory rate
Correct Answer: A
Rationale: The nurse’s priority assessment in ACS is the client’s pain; pain indicates that the heart is not receiving adequate oxygen and blood flow (perfusion). BP, HR, and RR are secondary as they stem from the lack of perfusion.
The client with atrial flutter is receiving a continuous infusion of 25,000 units of heparin in 500 mL of 5% dextrose at a rate of 12 mL per hour. The a PTT laboratory result is 92 seconds. According to the heparin infusion protocol, the nurse should administer the heparin infusion at a rate of how many mL per hour?
Correct Answer: 11
Rationale: According to the protocol, with an aPTT value of 92 seconds, the rate should be decreased by 1 mL per hour. If the infusion was previously infusing at 12 mL per hour, the new rate is 11 mL/hr.