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The nurse is caring for a client with cardiac tamponade. Which vital signs are expected?
- A. HR: 109 bpm; RR: 26; BP: 88/71 mmHg
- B. HR: 90 bpm; RR: 32; BP: 90/52 mmHg
- C. HR: 115 bpm; RR: 22; BP: 140/78 mmHg
- D. HR: 54 bpm; RR: 14; BP: 161/52 mmHg
Correct Answer: A
Rationale: Cardiac tamponade causes tachycardia (HR >100), increased respiratory rate, and hypotension due to restricted cardiac output.
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The nurse is reviewing laboratory data for a client suspected of having a myocardial infarction. The nurse anticipates that the CK-MB isoenzyme will peak within how many hours?
- A. 3 to 6 hours
- B. 1 to 2 hours
- C. 48 to 72 hours
- D. 18 hours
Correct Answer: D
Rationale: CK-MB peaks around 18 hours after a myocardial infarction, indicating myocardial damage.
Which of the following would be an expected finding in a client with infective endocarditis (IE)? Select all that apply.
- A. Fever
- B. Night sweats
- C. Osler nodes
- D. Cardiac murmur
- E. Syncope
- F. Weight loss
Correct Answer: A,B,C,D,F
Rationale: Fever is common due to infection. Night sweats are a systemic symptom of IE. C: Correct - Osler nodes are painful nodules associated with IE. D: Correct - Cardiac murmur results from valve involvement. E: Incorrect - Syncope is not a hallmark of IE. F: Correct - Weight loss occurs due to chronic infection.
The nurse assesses the following telemetry strip for a client on a medical-surgical unit. Based on the rhythm, what is the priority action for the nurse to take? See the exhibit.
- A. Prepare for synchronized cardioversion
- B. Obtain a prescription for intravenous (IV) atropine
- C. Review the client's most recent labs
- D. Assess if the client has a carotid pulse (P)
Correct Answer: D
Rationale: A life-threatening rhythm (e.g., ventricular tachycardia) requires immediate assessment of pulse to determine if the client is stable or needs resuscitation.
The nurse is caring for a client who has been ordered a sodium-restricted diet following a myocardial infarction. Which of the following meals would be most appropriate to suggest?
- A. Turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange.
- B. Broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk.
- C. Canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple.
- D. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.
Correct Answer: A
Rationale: Fresh foods like turkey, sweet potato, and green beans are low in sodium, unlike canned or processed foods.
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.