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The client's telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement?
- A. Document this as normal sinus rhythm.
- B. Request a 12-lead electrocardiogram.
- C. Prepare to administer the cardiotonic digoxin PO.
- D. Assess the client's cardiac enzymes.
Correct Answer: A
Rationale: P wave before QRS at rate 78 (A) is normal sinus rhythm, requiring documentation. ECG (B), digoxin (C), and enzymes (D) are unnecessary.
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Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction?
- A. Midepigastric pain and pyrosis.
- B. Diaphoresis and cool, clammy skin.
- C. Intermittent claudication and pallor.
- D. Jugular vein distention and dependent edema.
Correct Answer: B
Rationale: MI causes diaphoresis and cool, clammy skin (B) due to sympathetic activation. Epigastric pain/pyrosis (A) suggest GI issues, claudication/pallor (C) indicate PAD, and JVD/edema (D) suggest heart failure.
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 intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?
- A. Notify the health-care provider immediately.
- B. Elevate the head of the client's bed.
- C. Document this as a normal and expected finding.
- D. Administer morphine intravenously.
Correct Answer: A
Rationale: An S3 heart sound post-MI (A) indicates heart failure, requiring HCP notification. Elevating HOB (B) is supportive, documenting as normal (C) is incorrect, and morphine (D) is for pain.
The home health nurse is assigned a client diagnosed with heart failure. Which should the nurse implement? Select all that apply.
- A. Request a dietary consult for a sodium-restricted diet.
- B. Instruct the client to elevate the feet during the day.
- C. Teach the client to weigh every morning wearing the same type of clothing.
- D. Assess for edema in dependent areas of the body.
- E. Encourage the client to drink at least 3,000 mL of fluid per day.
- F. Have the client repeat back instructions to the nurse.
Correct Answer: A,B,C,D,F
Rationale: Sodium restriction (A), elevating feet (B), daily weights (C), edema assessment (D), and teach-back (F) manage CHF. 3,000 mL fluid (E) risks overload.
The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse?
- A. Muffled heart sounds.
- B. Nondistended jugular veins.
- C. Bounding peripheral pulses.
- D. Pericardial friction rub.
Correct Answer: A
Rationale: Muffled heart sounds (A) suggest cardiac tamponade, a life-threatening complication requiring immediate attention. Non-distended JVD (B) is normal, bounding pulses (C) are unrelated, and friction rub (D) is expected.