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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.
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What is the priority problem in the client diagnosed with congestive heart failure?
- A. Fluid volume overload.
- B. Decreased cardiac output.
- C. Activity intolerance.
- D. Knowledge deficit.
Correct Answer: B
Rationale: Decreased cardiac output (B) is the primary problem in CHF, causing symptoms like fluid overload (A). Activity intolerance (C) and knowledge deficit (D) are secondary.
The unlicensed assistive personnel (UAP) tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first?
- A. Tell the UAP to go take the client's vital signs.
- B. Ask the UAP to have the telemetry nurse read the strip.
- C. Notify the client's health-care provider.
- D. Go to the room and assess the client's chest pain.
Correct Answer: D
Rationale: Chest pain in CAD requires immediate nurse assessment (D) to determine severity and cause. Vital signs (A), telemetry (B), and notifying HCP (C) follow assessment.
The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina?
- A. Put a nitroglycerin tablet under the tongue.
- B. Stop the activity immediately and rest.
- C. Document when and what activity caused angina.
- D. Notify the health-care provider immediately.
Correct Answer: B
Rationale: Stopping activity and resting (B) reduces oxygen demand, the first step in angina. Nitroglycerin (A) follows, documenting (C) is later, and notifying HCP (D) is for persistent pain.
The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client?
- A. Instruct the client to use a soft-bristle toothbrush.
- B. Discuss the importance of getting a monthly partial thromboplastin time (PTT).
- C. Teach the client about signs of pacemaker malfunction.
- D. Explain to the client the procedure for synchronized cardioversion.
Correct Answer: A
Rationale: Atrial fibrillation requires anticoagulation, increasing bleeding risk; a soft-bristle toothbrush (A) prevents gum bleeding. PTT (B) monitors heparin, not warfarin, pacemakers (C) are unrelated, and cardioversion (D) is not routine.
The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.
- A. Notify the health-care provider of a weight gain of more than one (1) pound in a week.
- B. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
- C. Instruct the client to remove the saltshaker from the dinner table.
- D. Encourage the client to monitor urine output for change in color to become dark.
- E. Discuss the importance of taking the loop diuretic furosemide at bedtime.
Correct Answer: A,B,C
Rationale: Weight gain monitoring (A) detects fluid retention, pulse counting (B) ensures digoxin safety, and removing salt (C) reduces sodium intake. Dark urine (D) is not specific, and furosemide at bedtime (E) causes nocturia, so morning dosing is preferred.