Nokea
The nurse enters the client's room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. The concept of perfusion is identified by the nurse. Which should the nurse implement first?
- A. Notify the health care provider.
- B. Call a rapid response team (RRT).
- C. Determine the telemetry monitor reading.
- D. Push the Code Blue button.
Correct Answer: D
Rationale: No pulse/respirations indicate cardiac arrest; pushing the Code Blue button (D) initiates the code team. Notifying HCP (A), RRT (B), or checking telemetry (C) delay resuscitation.
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The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement?
- A. Instruct the UAP to stop encouraging the leg movements.
- B. Report this behavior to the charge nurse as soon as possible.
- C. Praise the UAP for encouraging the client to move the legs.
- D. Take no action concerning the UAP's behavior.
Correct Answer: C
Rationale: Leg movements (C) prevent DVT in MI patients on bedrest, so praising the UAP is appropriate. Stopping (A), reporting (B), or ignoring (D) are incorrect.
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 the physician's explanation of the PTCA procedure when the client makes which statement?
- A. A balloon-tipped catheter will be inserted into my coronary artery.
- B. A Teflon graft will be used to replace an area of my artery.
- C. A section of my leg vein will be grafted around a narrowed coronary artery.
- D. A battery-operated pacemaker will be implanted to maintain my heart rate.
Correct Answer: A
Rationale: PTCA involves inflating a balloon-tipped catheter to open a narrowed coronary artery, improving blood flow.
The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement?
- A. Instruct the client to keep a diary of activity, especially when having chest pain.
- B. Discuss the need to remove the Holter monitor during a.m. care and showering.
- C. Explain that all medications should be withheld while wearing a Holter monitor.
- D. Teach the client the importance of decreasing activity while wearing the monitor.
Correct Answer: A
Rationale: A diary (A) correlates symptoms with ECG changes on the Holter monitor. Removal (B) is incorrect, medications (C) continue, and decreasing activity (D) is unnecessary.
Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy?
- A. Keep the client in the supine position with the legs elevated.
- B. Discuss a heart transplant, which is the definitive treatment.
- C. Prepare the client for coronary artery bypass graft.
- D. Teach the client to take a calcium channel blocker in the morning.
Correct Answer: B
Rationale: Dilated cardiomyopathy may require heart transplant (B) as definitive treatment in severe cases. Supine position (A) increases preload, CABG (C) is for CAD, and calcium channel blockers (D) are not first-line.