Nokea
The nurse in the emergency department (ED) is assessing a client who may have an acute myocardial infarction. Which of the following findings would support this diagnosis?
- A. U-waves
- B. T-wave inversion
- C. ST-segment elevation
- D. Prolonged PR-interval
Correct Answer: C
Rationale: ST-segment elevation on ECG is a hallmark of acute myocardial infarction, indicating myocardial ischemia.
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The following scenario applies to the next 1 items
The nurse cares for a client admitted for a myocardial infarction
Item 1 of 1
Nurses' Note
0800 - Client was found in bed pale and diaphoretic, stating, I do not feel well. Approximately two minutes later, the cardiac monitor showed ventricular tachycardia. Upon assessment, the client became unresponsive and did not have a pulse.
For each potential intervention, click to specify if it is essential or contraindicated: A. Call a code blue, B. Cardiovert the client, C. Defibrillate the client, D. Anticipate a prescription for intravenous digoxin, E. Perform chest compressions
- A. Call a code blue
- B. Cardiovert the client
- C. Defibrillate the client
- D. Anticipate a prescription for intravenous digoxin
- E. Perform chest compressions
Correct Answer: A,C,E
Rationale: A: Essential - Calling a code blue activates the emergency response team for immediate intervention. B: Contraindicated - Cardioversion is used for synchronized shocks in stable rhythms like atrial fibrillation, not for pulseless ventricular tachycardia. C: Essential - Defibrillation is the treatment for pulseless ventricular tachycardia to restore a viable rhythm. D: Contraindicated - Digoxin is not used in acute cardiac arrest; it is for heart failure or rate control in arrhythmias. E: Essential - Chest compressions are required in pulseless clients as part of CPR.
The nurse observes the following tracing on the telemetry monitor. The nurse should take which initial action? See the image below.
- A. Assess the client's level of consciousness
- B. Prepare the client for immediate defibrillation
- C. Administer a dose of intravenous epinephrine
- D. Evaluate the client's cardiac lead placement
Correct Answer: B
Rationale: A life-threatening rhythm like ventricular fibrillation requires immediate defibrillation to restore normal rhythm.
The nurse is preparing a client for a scheduled percutaneous coronary intervention (PCI). Which statement made by the client should be reported to the primary healthcare provider (PHCP)
- A. I took my metformin this morning.
- B. I get anxious when I am in closed spaces.
- C. I am allergic to shellfish.
- D. I may feel a warm sensation during the procedure.
Correct Answer: C
Rationale: Shellfish allergy may indicate iodine sensitivity, relevant for contrast dye used in PCI, requiring PHCP notification.
Which of the following would cause an increase in cardiac output? Select all that apply.
- A. Increased stroke volume
- B. Increased blood volume
- C. Increased sympathetic stimulation
- D. Administration of positive inotropic drugs
- E. Increased systemic vascular resistance (SVR)
Correct Answer: A,B,C,D
Rationale: Increased stroke volume directly increases cardiac output. Increased blood volume enhances preload, boosting output. C: Correct - Sympathetic stimulation increases heart rate and contractility. D: Correct - Positive inotropes enhance contractility, increasing output. E: Incorrect - Increased SVR increases afterload, reducing cardiac output.
The nurse is assessing a client's cardiac rhythm strip and notices that it is irregular without any P waves before the QRS complexes. The nurse should interpret this as
- A. sinus tachycardia.
- B. sinus bradycardia.
- C. normal sinus rhythm with premature ventricular contractions (PVC).
- D. atrial fibrillation
Correct Answer: D
Rationale: Atrial fibrillation is characterized by an irregular rhythm and absent P waves due to chaotic atrial activity.