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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.
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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.
The client is three (3) hours post-myocardial infarction. Which data would warrant immediate intervention by the nurse?
- A. Bilateral peripheral pulses 2+.
- B. The pulse oximeter reading is 96%.
- C. The urine output is 240 mL in the last four (4) hours.
- D. Cool, clammy, diaphoretic skin.
Correct Answer: D
Rationale: Cool, clammy, diaphoretic skin (D) indicates cardiogenic shock or sympathetic response, requiring immediate intervention. Pulses (A), SpO2 (B), and urine output (C) are normal.
The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?
- A. Notify the health-care provider.
- B. Document that the pericarditis has resolved.
- C. Ask the client to lean forward and listen again.
- D. Prepare to insert a unilateral chest tube.
Correct Answer: C
Rationale: Leaning forward (C) enhances auscultation of a pericardial friction rub, which may be positional. Notifying HCP (A), documenting resolution (B), or chest tube (D) are premature or unrelated.
The nurse has written an outcome goal 'demonstrates tolerance for increased activity' for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome?
- A. Measure intake and output.
- B. Provide two (2)g sodium diet.
- C. Weigh the client daily.
- D. Plan for frequent rest periods.
Correct Answer: D
Rationale: Frequent rest periods (D) prevent overexertion, supporting activity tolerance in CHF. Intake/output (A), sodium diet (B), and daily weights (C) are important but less directly related to activity.
The client has an implantable cardioverter defibrillator (ICD). Which discharge instructions should the nurse teach the client?
- A. Do not lift or carry more than 23 kg.
- B. Have someone drive the car for the rest of your life.
- C. Carry the cell phone on the opposite side of the ICD.
- D. Avoid using the microwave oven in the home.
Correct Answer: C
Rationale: Carrying the cell phone on the opposite side (C) minimizes electromagnetic interference with the ICD. Lifting limits (A) are typically 10–15 lbs initially, driving (B) is restricted temporarily, and microwaves (D) are safe.