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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.
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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.
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.
The nurse is caring for a client diagnosed with coronary artery disease (CAD). Which should the nurse teach the client prior to discharge?
- A. Carry your nitroglycerin tablets in a brown bottle.
- B. Swallow a nitroglycerin tablet at the first sign of angina.
- C. If one nitroglycerin tablet does not work in 10 minutes, take another.
- D. Nitroglycerin tablets have a fruity odor if they are potent.
Correct Answer: A
Rationale: Nitroglycerin should be stored in a dark bottle (A) to maintain potency. Swallowing (B) is incorrect (sublingual), 10 minutes (C) should be 5, and fruity odor (D) is not a potency indicator.
The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective?
- A. The client's peripheral pitting edema has gone from 3+ to 4+.
- B. The client is able to take the radial pulse accurately.
- C. The client is able to perform ADLs without dyspnea.
- D. The client has minimal jugular vein distention.
Correct Answer: C,D
Rationale: Effective CHF treatment reduces fluid overload, allowing ADLs without dyspnea (C) and minimal JVD (D). Increased edema (A) indicates worsening, and pulse-taking (B) is a skill, not a treatment outcome.
The client is in complete heart block. Which intervention should the nurse implement first?
- A. Prepare to insert a pacemaker.
- B. Administer atropine, an antidysrhythmic.
- C. Obtain a STAT electrocardiogram (ECG).
- D. Notify the health-care provider.
Correct Answer: B
Rationale: Complete heart block may respond to atropine (B) to increase heart rate acutely. Pacemaker (A), ECG (C), and HCP notification (D) follow if atropine fails.