Nokea
The nurse is taking the BP on multiple clients. Which reading warrants the nurse notifying the HCP because the client’s MAP is abnormal?
- A. 94/60 mm Hg
- B. 98/36 mm Hg
- C. 110/50 mm Hg
- D. 140/78 mm Hg
Correct Answer: B
Rationale: The Mean Arterial Pressure (MAP) is calculated as (SBP + 2*DBP)/3. For 98/36 mm Hg: (98 + 2*36)/3 = (98 + 72)/3 = 170/3 ≈ 56.67 mm Hg, which is abnormally low (normal MAP is 70-100 mm Hg), indicating potential hypoperfusion. Other readings yield: A: (94 + 2*60)/3 ≈ 71.33 mm Hg, C: (110 + 2*50)/3 ≈ 70 mm Hg, D: (140 + 2*78)/3 ≈ 98.67 mm Hg, all within or closer to normal range.
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The client with a left anterior descending (LAD) 90% blockage has crushing chest pain that is unrelieved by taking sublingual nitroglycerin. Which ECG finding is most concerning and should alert the nurse to immediately notify the HCP?
- A. Q waves
- B. Flipped T waves
- C. Peaked T waves
- D. ST segment elevation
Correct Answer: D
Rationale: The nurse should be most concerned about ST elevation because it indicates an evolving MI. Q waves suggest a previous MI, flipped T waves indicate ischemia, and peaked T waves may indicate hyperkalemia, but ST elevation is the most acute and critical finding.
The client, returning from a coronary catheterization in which the femoral artery approach was used, sneezes. Which should be the nurse’s priority intervention?
- A. Palpate pedal pulses
- B. Measure vital signs
- C. Assess for urticaria
- D. Check the insertion site
Correct Answer: D
Rationale: Checking the insertion site is priority. Sneezing increases intra-abdominal pressure and increases the risk for clot disruption and bleeding from the femoral artery. Pedal pulses, vital signs, and urticaria are secondary concerns.
The client newly diagnosed with HF has an ejection fraction of 20%. Which criteria should the nurse use to evaluate the client’s readiness for discharge to home? Select all that apply.
- A. There is a scale in the client’s home
- B. The client started ambulating 24 hours ago
- C. The client is receiving furosemide IV 20 mg bid
- D. A smoking cessation consult is scheduled for 2 days after discharge
- E. A home-care nurse is scheduled to see the client 3 days after discharge
Correct Answer: A;B;E
Rationale: The nurse should evaluate: A) A scale to monitor fluid status; B) Ambulation to confirm functional capability; E) Home-care nurse visit within 3 days for support. IV furosemide (C) should be oral before discharge, and smoking cessation (D) should start before discharge.
The nurse is admitting the client with a new diagnosis of persistent atrial fibrillation with rapid ventricular response. The client has been in atrial fibrillation for more than 2 days and has had no previous cardiac problems. Which initial interventions should the nurse anticipate? Select all that apply.
- A. Ablation of the AV node
- B. Immediate cardioversion
- C. Oxygen 2 liters per nasal cannula
- D. Heparin intravenous (IV) infusion
- E. Amiodarone IV infusion
- F. Diltiazem IV infusion
Correct Answer: C;D;E;F
Rationale: The nurse should anticipate: C) Oxygen to enhance tissue oxygenation due to decreased cardiac output; D) Heparin to prevent thromboembolism from atrial stasis; E) Amiodarone for pharmacological cardioversion; F) Diltiazem to slow ventricular response. Ablation and cardioversion are considered only if medications fail or after ruling out atrial clots.
The nurse is caring for the client who had a cardiac valve replacement. To decrease the risk of DVT and PE, which interventions should the nurse plan to include? Select all that apply.
- A. Apply a pneumatic compression device.
- B. Administer a heparin infusion intravenously.
- C. Encourage coughing and deep breathing hourly.
- D. Teach about performing isometric leg exercises.
- E. Avoid the use of graded compression elastic stockings.
Correct Answer: A;D
Rationale: The nurse should include: A) Pneumatic compression devices to mimic walking pressures; D) Isometric exercises to compress vessels and reduce DVT risk. Heparin is typically subcutaneous, coughing/deep breathing prevents pulmonary issues, and compression stockings are beneficial unless PAD is present.