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The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication?
- A. The client's apical pulse is 64.
- B. The client's calcium level is elevated.
- C. The client's telemetry shows occasional PVCs.
- D. The client's blood pressure is 90/58.
Correct Answer: D
Rationale: Hypotension (BP 90/58, D) contraindicates calcium channel blockers, which lower BP further. Pulse 64 (A), elevated calcium (B), and PVCs (C) are not contraindications.
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The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor?
- A. The client admitted for diagnostic tests to rule out valvular heart disease.
- B. The client three (3) days post-myocardial infarction being discharged tomorrow.
- C. The client exhibiting supraventricular tachycardia (SVT) on telemetry.
- D. The client diagnosed with atrial fibrillation who has an INR of five (5).
Correct Answer: A
Rationale: Diagnostic testing for valvular disease (A) is stable, suitable for a new graduate. Post-MI (B), SVT (C), and high INR (D) require experienced care.
The nurse is caring for a client who suddenly complains of crushing substernal chest pain while ambulating in the hall. Which nursing action should the nurse implement first?
- A. Call a Code Blue.
- B. Assess the telemetry reading.
- C. Take the client's apical pulse.
- D. Have the client sit down.
Correct Answer: D
Rationale: Crushing chest pain suggests ischemia; sitting down (D) reduces oxygen demand. Code Blue (A), telemetry (B), and pulse (C) follow if pain persists.
The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching?
- A. The client takes prophylactic antibiotics.
- B. The client uses a soft-bristle toothbrush.
- C. The client takes an enteric-coated aspirin daily.
- D. The client alternates rest with activity.
Correct Answer: C
Rationale: Aspirin (C) is not routinely required post-mechanical valve; warfarin is standard. Antibiotics (A), soft toothbrush (B), and rest/activity (D) are appropriate.
The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure?
- A. Perform passive range-of-motion exercises.
- B. Assess the client's neurovascular status.
- C. Keep the client in high Fowler's position.
- D. Assess the gag reflex prior to feeding the client.
Correct Answer: B
Rationale: Post-catheterization, assessing neurovascular status (B) ensures no bleeding or vascular complications. ROM (A) is inappropriate, high Fowler’s (C) is not required, and gag reflex (D) is irrelevant.
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
- A. Assist the client to go down to the smoking area for a cigarette.
- B. Transport the client to the intensive care unit (ICU) via a stretcher.
- C. Provide the client going home discharge-teaching instructions.
- D. Help position the client who is having a portable x-ray done.
Correct Answer: D
Rationale: Positioning for an x-ray (D) is within the UAP’s scope and safe. Smoking (A) is inappropriate, ICU transport (B) requires nursing judgment, and discharge teaching (C) is a nursing responsibility.