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The nurse is caring for a client recovering from myocardial infarction who is presenting with a heart rate of 110 beats per minute, a blood pressure of 86/58 mmHg, crackles, shortness of breath, dusky skin, and jugular vein distention. Which action should the nurse recognize as the highest priority?
- A. Administer medications to increase stroke volume.
- B. Provide analgesics.
- C. Obtain a STAT electrocardiogram and troponins.
- D. Administer fluid replacement to increase blood pressure.
Correct Answer: D
Rationale: These findings suggest cardiogenic shock with pulmonary edema. Fluid replacement may be needed, but cautiously, to optimize preload.
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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.
The nurse has taught a client newly prescribed sublingual nitroglycerin for acute angina. Which of the following statements by the client would require follow-up?
- A. I will get a refill of my prescription every six months.
- B. I will take one tablet every 2 minutes if chest pain occurs.
- C. I will place my medication in a dark amber bottle.
- D. I must not chew on the tablet when taking it.
Correct Answer: B
Rationale: Nitroglycerin should be taken every 5 minutes (up to 3 doses) for chest pain, not every 2 minutes, to avoid overdose.
The nurse assesses a client three hours following cardiac surgery. Assessment findings were a blood pressure of 88/52 mm Hg, jugular venous distention, and muffled heart sounds. The nurse anticipates that this client will need an immediate
- A. thoracentesis.
- B. pericardiocentesis.
- C. arthrocentesis.
- D. paracentesis.
Correct Answer: B
Rationale: These findings suggest cardiac tamponade, requiring pericardiocentesis to remove fluid compressing the heart.
The nurse is assisting the primary health care provider (PHCP) with an elective electrical cardioversion for a chronic atrial fibrillation client. Prior to this procedure, the nurse should perform which action?
- A. Remove the client's peripheral vascular access device.
- B. Review the client's risk factors for post-procedure bleeding.
- C. Ensure that a water-seal chest tube drainage device is readily available.
- D. Verify that the informed consent has been obtained by the health care provider (HCP).
Correct Answer: D
Rationale: Informed consent is required for elective cardioversion, a procedure with risks like thromboembolism.
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.