Nokea
The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement?
- A. Assess the apical heart rate for one (1) full minute.
- B. Notify the client's cardiac surgeon.
- C. Prepare the client for synchronized cardioversion.
- D. Determine if the client is having pain.
Correct Answer: D
Rationale: Sinus tachycardia post-CABG is often due to pain (D), which should be assessed first. Heart rate (A), notifying (B), and cardioversion (C) follow if needed.
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When obtaining a health history from this client, which finding strongly suggests that the client is hypertensive? Select all that apply.
- A. Unexplained nosebleeds
- B. Difficulty sleeping at night
- C. Waking to urinate at night
- D. Occasional heart palpitations
- E. Dizziness
- F. Pale skin color
Correct Answer: A,C,E
Rationale: Unexplained nosebleeds, waking to urinate at night (nocturia), and dizziness are symptoms associated with hypertension due to increased vascular pressure, kidney effects, and cerebral hypoperfusion, respectively.
The nurse knows that the client understands how to determine when the nitroglycerin tablets need replacing when the client makes which statement?
- A. The tablets will be discovered.
- B. The tablets will be discolored.
- C. They won't tingle in my mouth.
- D. They will disintegrate when I touch them.
Correct Answer: C
Rationale: Fresh nitroglycerin tablets cause a tingling sensation under the tongue; loss of this sensation indicates loss of potency.
An adult client who has peripheral vascular disease of the lower extremities was observed smoking in the waiting area. What is the most appropriate response for the nurse to make regarding the client's smoking?
- A. Smoking is not allowed for patients with blood diseases.'
- B. Smoking causes the blood vessels in your legs to constrict and reduces the blood supply.'
- C. Smoking increases your blood pressure and strains your heart.'
- D. Smoking causes your body to be under greater stress.'
Correct Answer: B
Rationale: Smoking causes vasoconstriction, worsening blood flow in peripheral vascular disease, which directly impacts the condition. Other responses are less specific to the client’s diagnosis.
Which of the following electrocardiogram (ECG) changes supports the diagnosis that the client is experiencing a myocardial infarction (MI)?
- A. Inverted P wave
- B. Prolonged PR interval
- C. Widened QRS complex
- D. Elevated ST segment
Correct Answer: D
Rationale: ST-segment elevation on ECG is a hallmark of acute myocardial infarction, indicating myocardial ischemia.
To assess the area where the permanent pacemaker battery, the nurse knows to examine which area of the skin?
- A. Beneath the left nipple
- B. Near the brachial artery
- C. In the midsternal area
- D. Below the right clavicle
Correct Answer: D
Rationale: Pacemaker generators are typically implanted below the right clavicle.