Nokea
The nurse is assessing the client following cardiac surgery. Which assessment findings should be of the greatest concern to the nurse?
- A. Jugular vein distention, muffled heart sounds, and BP 84/48
- B. Temperature 96.4°F (35.8°C), heart rate 58 bpm, and shivering
- C. Increased heart rate, audible S1 and S2, and pain rated at a 5
- D. Central venous pressure (CVP) 4 mm Hg, urine output 30 mL/hr, and sinus rhythm with a few PVCs
Correct Answer: A
Rationale: The nurse should be most concerned with JVD, muffled heart sounds, and hypotension (Beck’s Triad). This is a life-threatening event suggesting cardiac tamponade. Other findings are expected post-surgery or less critical.
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The clinic nurse is teaching the client at risk for developing arteriosclerosis. The nurse should teach the client that the dietary therapy to decrease homo-cysteine levels includes eating foods rich in which nutrient?
- A. Monosaturated fats
- B. B complex Vitamins
- C. Vitamin C
- D. Calcium
Correct Answer: B
Rationale: Homocysteine interferes with the elasticity of the endothelial layer in blood vessels. Foods rich in B-complex vitamins, especially folic acid, have been found to lower serum homocysteine levels. Monosaturated fats, Vitamin C, and Calcium do not have a direct effect on homocysteine levels.
The client with a left anterior descending (LAD) 90% blockage has crushing chest pain that is unrelieved by taking sublingual nitroglycerin. Which ECG finding is most concerning and should alert the nurse to immediately notify the HCP?
- A. Q waves
- B. Flipped T waves
- C. Peaked T waves
- D. ST segment elevation
Correct Answer: D
Rationale: The nurse should be most concerned about ST elevation because it indicates an evolving MI. Q waves suggest a previous MI, flipped T waves indicate ischemia, and peaked T waves may indicate hyperkalemia, but ST elevation is the most acute and critical finding.
The client newly diagnosed with HF has an ejection fraction of 20%. Which criteria should the nurse use to evaluate the client’s readiness for discharge to home? Select all that apply.
- A. There is a scale in the client’s home
- B. The client started ambulating 24 hours ago
- C. The client is receiving furosemide IV 20 mg bid
- D. A smoking cessation consult is scheduled for 2 days after discharge
- E. A home-care nurse is scheduled to see the client 3 days after discharge
Correct Answer: A;B;E
Rationale: The nurse should evaluate: A) A scale to monitor fluid status; B) Ambulation to confirm functional capability; E) Home-care nurse visit within 3 days for support. IV furosemide (C) should be oral before discharge, and smoking cessation (D) should start before discharge.
The client is prescribed to have an elastic bandage applied to the lower extremity to reduce edema. At which position on the client’s leg should the nurse start wrapping the elastic bandage?
- A. Location A
- B. Location B
- C. Location C
- D. Location D
Correct Answer: D
Rationale: The nurse should begin to apply the bandage at the distal point and proceed proximally. By starting at this point, trapping fluid atop the foot is avoided. The purpose of the bandage is to apply compression evenly to the lower leg. Starting at the knee, calf, or ankle increases edema distally.
The nurse is admitting the client with a new diagnosis of persistent atrial fibrillation with rapid ventricular response. The client has been in atrial fibrillation for more than 2 days and has had no previous cardiac problems. Which initial interventions should the nurse anticipate? Select all that apply.
- A. Ablation of the AV node
- B. Immediate cardioversion
- C. Oxygen 2 liters per nasal cannula
- D. Heparin intravenous (IV) infusion
- E. Amiodarone IV infusion
- F. Diltiazem IV infusion
Correct Answer: C;D;E;F
Rationale: The nurse should anticipate: C) Oxygen to enhance tissue oxygenation due to decreased cardiac output; D) Heparin to prevent thromboembolism from atrial stasis; E) Amiodarone for pharmacological cardioversion; F) Diltiazem to slow ventricular response. Ablation and cardioversion are considered only if medications fail or after ruling out atrial clots.