Nokea
The nurse in the medical-surgical unit is observing the telemetry monitor for assigned clients. Which client condition change requires immediate notification to the primary healthcare provider (PHCP)? A client
- A. with normal sinus rhythm (NSR), who has had three premature ventricular contractions (PVCs) in the past hour.
- B. recovering from cardiac catheterization and has had two brief runs of ventricular tachycardia (VT).
- C. with atrial fibrillation, whose heart rate decreased from 113 to 95 beats per minute.
- D. who has developed sinus tachycardia (ST) following the application of nitroglycerin paste.
Correct Answer: B
Rationale: Ventricular tachycardia is life-threatening and requires immediate PHCP notification, unlike the other less urgent findings.
You may also like to solve these questions
The nurse is caring for a client in the emergency department, reporting a headache and generalized flushing. The nurse should request a prescription for which medication? See the exhibit for additional client information.
- A. enalapril
- B. labetalol
- C. amiodarone
- D. nitroglycerin
Correct Answer: B
Rationale: Headache and flushing in a hypertensive crisis suggest the need for labetalol, a beta-blocker, to control blood pressure.
The nurse is providing discharge teaching to a client following coronary artery bypass graft (CABG) surgery. The nurse should advise the client that they may resume sexual activity
- A. after exercise tolerance is assessed.
- B. one week after surgery.
- C. when the client can comfortably jog two miles.
- D. three months after surgery.
Correct Answer: A
Rationale: Sexual activity can resume after CABG once exercise tolerance is confirmed, typically when the client can climb two flights of stairs without symptoms.
Which of the following findings would the nurse expect to observe in a client who has developed cardiac tamponade? Select all that apply.
- A. Unilateral crackles
- B. Systolic murmur
- C. Bradycardia
- D. Jugular venous distention
- E. Hypotension
Correct Answer: D,E
Rationale: Unilateral crackles suggest pulmonary issues, not tamponade. B: Incorrect - Systolic murmur is not specific to tamponade. C: Incorrect - Tachycardia, not bradycardia, is typical in tamponade due to compensatory mechanisms. D: Correct - Jugular venous distention occurs due to increased venous pressure. E: Correct - Hypotension results from reduced cardiac output in tamponade.
The nurse is caring for a client who appears to be developing heart failure (HF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis?
- A. Basic metabolic panel (BMP)
- B. B-type natriuretic peptide (BNP)
- C. Lipid profile
- D. Troponin
Correct Answer: B
Rationale: BNP is a specific biomarker elevated in heart failure, reflecting ventricular stress and fluid overload.
History of Present Illness (HPI)
The client was found disoriented upon arrival and in acute respiratory distress.
The client's caregiver noted that the prescribed medications had not been
taken for several days. Medical history includes hypertension, diabetes mellitus,
congestive heart failure, and arthritis. Client Assessment Bounding peripheral pulses,
normotensive, crackles in the lung fields, tachypnea, jugular venous distention, and
abdominal distention.
Diagnosis
1. Pulmonary edema
2. Acute decompensated heart failure
Based on the clinical data, which prescription would the nurse request from the primary healthcare provider for a client with pulmonary edema and acute decompensated heart failure? Select all that apply.
- A. Albuterol
- B. Hydrocortisone
- C. Diltiazem
- D. Nitroglycerin
- E. Furosemide
Correct Answer: D,E
Rationale: Albuterol is for bronchospasm, not pulmonary edema. B: Incorrect - Hydrocortisone is not indicated for heart failure. C: Incorrect - Diltiazem is for rate control, not fluid overload. D: Correct - Nitroglycerin reduces preload, alleviating pulmonary edema. E: Correct - Furosemide is a diuretic to reduce fluid overload.