Nokea
The nurse has received shift report. Which client should the nurse assess first?
- A. The client diagnosed with coronary artery disease complaining of severe indigestion.
- B. The client diagnosed with congestive heart failure who has 3+ pitting edema.
- C. The client diagnosed with atrial fibrillation whose apical rate is 110 and irregular.
- D. The client diagnosed with sinus bradycardia who is complaining of being constipated.
Correct Answer: A
Rationale: Severe indigestion in CAD (A) may indicate angina or MI, requiring immediate assessment. Edema (B), tachycardia (C), and constipation (D) are less urgent.
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The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented?
- A. Administer a thrombolytic medication.
- B. Assess the client's cardiovascular status.
- C. Prepare for insertion of a pacemaker.
- D. Obtain a permit for synchronized cardioversion.
Correct Answer: C
Rationale: Symptomatic bradycardia (syncope, hypotension) often requires a pacemaker (C). Thrombolytics (A) are for MI, assessment (B) is ongoing, and cardioversion (D) is for tachydysrhythmias.
An adult who is receiving heparin asks the nurse why it cannot be given by mouth. The nurse responds that heparin is given parenterally because:
- A. it is destroyed by gastric secretions.
- B. it irritates the gastric mucosa.
- C. it irritates the intestinal lining.
- D. therapeutic levels can be achieved more quickly.
Correct Answer: AUG
Rationale: Heparin is a protein and is destroyed by gastric secretions, requiring parenteral administration (intravenously or subcutaneously). It does not irritate the gastric or intestinal lining, and while parenteral administration allows faster therapeutic levels, the primary reason is its destruction in the stomach.
The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client?
- A. Explain the importance of tapering off the medication.
- B. Discuss that the medication will make the client drowsy.
- C. Instruct the client to take the medication with food.
- D. Tell the client to take the medication when the pain level is around '8.'
Correct Answer: C
Rationale: NSAIDs irritate the stomach; taking with food (C) reduces GI upset. Tapering (A) is for steroids, drowsiness (B) is not typical, and waiting for severe pain (D) delays relief.
Where is the correct placement for the nurse's hands before administering cardiac compressions?
- A. On the lower half of the sternum
- B. On the lower half of the xiphoid process
- C. Over the costal cartilage
- D. Directly above the manubrium
Correct Answer: A
Rationale: Hands are placed on the lower half of the sternum (center of the chest) for effective CPR compressions.
During the postoperative period, what is the best rationale for the nurse frequently assessing the client's fluid status?
- A. Urine retention is common after a heart transplant.
- B. Urine output is an indication of perfusion to the kidneys.
- C. Hydration determines when the client needs to be transfused.
- D. Hydration indicates when fluids should be increased.
Correct Answer: B
Rationale: Urine output reflects renal perfusion, critical post-heart transplant to monitor graft function.