Nokea
The nurse is teaching a client who is scheduled for an exercise electrocardiography (ECG) test. Which of the following statements by the client would require follow-up?
- A. I should wear loose, comfortable clothing with non-slip athletic footwear.
- B. I may have a small cup of coffee before the exam.
- C. I will have my blood pressure, heart rate, and rhythm obtained before, during, and after the stress test.
- D. I should not do any strenuous activity before the test.
Correct Answer: B
Rationale: Caffeine can affect heart rate and ECG results, so coffee should be avoided before an exercise ECG test.
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Which of the following should the nurse do for a client reporting chest pain radiating to the arm? Select all that apply.
- A. Obtain an electrocardiogram (ECG)
- B. Prepare the client for cardioversion
- C. Establish intravenous (IV) access
- D. Insert an indwelling urinary catheter
- E. Administer prescribed nitroglycerin
Correct Answer: A,C,E
Rationale: ECG is critical to diagnose the cause of chest pain. B: Incorrect - Cardioversion is for specific arrhythmias, not chest pain alone. C: Correct - IV access is needed for potential medications. D: Incorrect - Urinary catheter is not indicated for chest pain. E: Correct - Nitroglycerin relieves ischemic chest pain.
Which of the following statements should the nurse include when teaching a community health course on adult cardiopulmonary resuscitation (CPR)? Select all that apply.
- A. The compression rate is 100 to 120 per minute.
- B. The compression depth should be 1.5 inches.
- C. Allow full chest recoil between compressions.
- D. Rotate compressor at least every 2 minutes.
- E. Stop to check your pulse every 30 seconds.
Correct Answer: A,C,D
Rationale: Compression rate of 100-120/min ensures adequate circulation. B: Incorrect - Depth should be 2-2.4 inches in adults. C: Correct - Full chest recoil maximizes venous return. D: Correct - Rotating compressors prevents fatigue. E: Incorrect - Pulse checks are done after rhythm checks, not every 30 seconds.
An emergency department nurse is caring for a client who presented with fatigue, muscular weakness, and dyspnea. Upon assessment, the client was noted to be coughing frequently and sitting in a tripod position. A subsequent diagnosis of left ventricular failure was made. The nurse understands that manifestations of left-sided heart failure present as respiratory issues because:
- A. There is venous congestion in the liver.
- B. There is hypoperfusion of tissue cells.
- C. There is pulmonary congestion.
- D. Despite normal cardiac output, the heart cannot meet the accelerated demands of the body.
Correct Answer: C
Rationale: Left-sided heart failure causes pulmonary congestion, leading to respiratory symptoms like dyspnea and cough.
The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated?
- A. Apply TED hose to bilateral legs
- B. Assess the need for smoking cessation
- C. Physical therapy consult
- D. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler
Correct Answer: A
Rationale: TED hose are contraindicated in arterial insufficiency (indicated by weak pulses and hair loss), as they may worsen ischemia.
A 45-year-old client is admitted to the medical telemetry unit to observe for possible dysrhythmias. After waking in the morning, the client asks the nurse for coffee. Which of the following would be the best response by the nurse?
- A. Hot beverages are not allowed because of the condition of your heart.
- B. Coffee is not included in your diet ordered by your health care provider (HCP).
- C. We don't have coffee on the unit. I can bring you some tea if you would like.
- D. Currently, you cannot have coffee as it contains caffeine, which can adversely affect your heart.
Correct Answer: D
Rationale: Caffeine can exacerbate dysrhythmias by stimulating the heart, making it contraindicated in this context.