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The nurse is caring for a client newly admitted with infective endocarditis (IE). The nurse should plan for which intervention in the client's care plan?
- A. initiating contact and droplet precautions
- B. obtain a prescription for intravenous antivirals
- C. obtain a prescription for enoxaparin
- D. monitor renal function
Correct Answer: D
Rationale: Infective endocarditis can cause glomerulonephritis, necessitating renal function monitoring (e.g., creatinine levels).
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The nurse assesses the following electrocardiogram (ECG) strips for assigned clients. The nurse should immediately follow up with the client with which ECG strip?
- A. QSTN 8-A.png
- B. QSTN 8-B.png
- C. QSTN 8-C.png
- D. QSTN 8-D.png
Correct Answer: A
Rationale: Without specific ECG details, the nurse prioritizes the strip indicating life-threatening arrhythmias (e.g., ventricular tachycardia or fibrillation) requiring immediate intervention.
The nurse is caring for a client who has sustained a myocardial infarction. Which laboratory test would be increased that is specific to myocardium damage?
- A. CPK-MB
- B. Troponin
- C. Creatinine kinase
- D. Myoglobin
Correct Answer: B
Rationale: Troponin is the most specific marker for myocardial damage, remaining elevated for days post-MI.
The following scenario applies to the next 6 items
The client is a 72-year-old male who presents to the emergency department with increasing
shortness of breath over the past two days that gets worse when he is lying flat in bed at night.
Item 1 of 6
History And Physical Nurses' Notes Flow Sheet
0700: The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. He states, "I feel like I can't catch my breath," and he had to sleep in a recliner. He reports a 4 lb weight gain over the last week and increasing fatigue. The client is alert and oriented but is using his accessory muscles to breathe. He reports feeling short of breath, orthopnea, and paroxysmal nocturnal dyspnea. He has bilateral pedal edema (+2), bilateral crackles heard upon auscultation, and jugular vein distention noted on his assessment. The
the client has a medical history of hypertension, coronary artery disease, and a prior myocardial infarction. He was diagnosed with heart failure with reduced ejection fraction (HFrEF) two years ago. Current home medications include lisinopril, metoprolol succinate, furosemide, and atorvastatin.
The nurse knows that the priority concept associated with the client's condition is ………….caused by a reduction in…………
- A. Oxygenation
- B. Perfusion
- C. Gas exchange
- D. Cardiac output
- E. Hemoglobin concentration
- F. Fluid balance
Correct Answer: B,D
Rationale: Heart failure is primarily a condition of reduced perfusion (B) due to decreased cardiac output (D), impairing the heart's ability to pump blood effectively.
The nurse has instructed a client who is scheduled to have a transesophageal echocardiogram (TEE). Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I will need to take antibiotics for one week following this test.
- B. This test will determine if I have any blood clots in my heart.
- C. I will receive general anesthesia for this procedure.
- D. I may feel a flushing sensation when the contrast dye is given.
Correct Answer: B
Rationale: TEE is used to detect intracardiac thrombi, such as in atrial fibrillation, making this statement correct.
The nurse cares for a client with a complete (3rd-degree) heart block and hypotension. The nurse should take which appropriate action?
- A. prepare the client for temporary transcutaneous pacing
- B. obtain a prescription for an esmolol infusion
- C. begin chest compressions
- D. instruct the client to perform the Valsalva maneuver
Correct Answer: A
Rationale: Complete heart block with hypotension requires urgent pacing to restore adequate heart rate and cardiac output.