Nokea
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.
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The nurse is caring for the client following a coronary artery bypass graft. Which assessment finding in the immediate postoperative period should be most concerning to the nurse?
- A. Copious chest tube output; now none for 1 hour
- B. Current core temperature of 101.3°F (38.5°C)
- C. pH 7.32; Paco2 48; HCO3 28; Pao2 80
- D. Urine output 160 mL in the last 4 hours
Correct Answer: A
Rationale: A copiously draining chest tube that is no longer draining indicates an obstruction. It should be most concerning because there is an increased risk for cardiac tamponade or pleural effusion. Slight fever, compensated respiratory acidosis, and adequate urine output are less urgent.
Two days ago the client underwent femoral popliteal artery bypass graft surgery. What should be the nurse’s priority at this time?
- A. Monitor intake and output every four hours.
- B. Report any edema that develops in the operative leg.
- C. Place the client in a 60-degree sitting position when in bed.
- D. Check pedal and post tibial pulses bilaterally every 4 hours.
Correct Answer: D
Rationale: The priority nursing action should be to monitor the pulses in the feet to detect graft occlusion. Checking both sides allows for comparison. I&O, edema, and positioning are secondary.
The client states to the clinic nurse, “I had pain in the left calf for a few days earlier in the week, but I am pain free now.” The nurse’s assessment findings include: dorsalis pedis pulses palpable, no pain upon dorsiflexion bilaterally, a few visible varicose veins in each leg, and slight swelling in only the left leg. Which is the nurse’s best action?
- A. Ask if the client has been walking more lately.
- B. Inform the HCP of the assessment findings.
- C. Ask if the client has considered taking a baby aspirin daily.
- D. Explain to the client that there are no significant findings.
Correct Answer: B
Rationale: The nurse should inform the HCP about the assessment findings. A possible DVT is taken seriously because it can lead to PE. Unilateral swelling of one leg is a classic symptom of DVT. Additional questions, aspirin advice, or dismissing findings are inappropriate without further evaluation.
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 increases activity for the client with an admitting diagnosis of ACS. Which client finding best supports that the client is not tolerating the activity?
- A. Pulse rate increased by 15 beats per minute during activity
- B. BP 130/86 mm Hg before activity; 108/66 mm Hg during activity
- C. Increased dyspnea and diaphoresis relieved when sitting in a chair
- D. A mean arterial pressure (MAP) of 80 following activity
Correct Answer: B
Rationale: A drop in BP of 20 mm Hg from the baseline indicates that the client’s heart is unable to adapt to the increased energy and oxygen demands of the activity. The client is not tolerating the activity; the length of time or the intensity should be reduced. A modest pulse increase, relieved symptoms, and normal MAP are less concerning.