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The nurse is watching the monitor of a client wearing a continuous cardiac monitor when it begins to alarm and fails to display any QRS complexes. Which nursing intervention should the nurse do first?
- A. Press record on the electrocardiogram
- B. Check the client's lead placement
- C. Call the code team
- D. Contact the health care provider
Correct Answer: B
Rationale: Absent QRS complexes may result from loose or disconnected leads, so checking lead placement is the first step.
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The nurse is caring for a client with a myocardial infarction experiencing tachycardia and coughing up frothy, pink-tinged sputum. Which finding would the nurse expect upon lung auscultation?
- A. Wheezing
- B. Crackles
- C. Rhonchi
- D. Diminished sounds
Correct Answer: B
Rationale: Frothy, pink-tinged sputum indicates pulmonary edema, often post-MI, causing crackles on lung auscultation due to fluid in alveoli.
The nurse has attended a staff education program about managing clients with peripheral arterial disease. Which of the following statements by the nurse would require follow-up?
- A. The client should engage in a daily exercise regimen.
- B. Smoking cessation is an essential treatment goal for clients who smoke.
- C. Resting in a recliner with the legs dependent should be recommended.
- D. Devices that elevate the legs above the heart should be provided at discharge.
Correct Answer: C
Rationale: Dependent leg positioning worsens peripheral arterial disease by reducing blood flow; elevation is contraindicated.
The nurse is caring for a client who was recently admitted to the cardiac floor for angina. This client states that their chest pain occurs at the same time every day at rest. The client does not believe there are any precipitating factors. Which of the following types of angina is this client most likely experiencing?
- A. Variant angina
- B. Stable angina
- C. Unstable angina
- D. Nonanginal pain
Correct Answer: A
Rationale: Variant (Prinzmetal's) angina occurs at rest, often at predictable times, due to coronary artery spasm, not exertion, unlike stable or unstable angina.
The nurse has collected a client's vital signs. The nurse notes that the client's apical pulse was 75 beats per minute, and the radial pulse was 69 beats per minute. The nurse should document this finding as
- A. a widened pulse pressure.
- B. a pulse deficit.
- C. pulsus paradoxus.
- D. an expected finding.
Correct Answer: B
Rationale: A difference between apical and radial pulses indicates a pulse deficit, often due to weak or missed beats.
The nurse assesses the following electrocardiogram (ECG) strips for assigned clients. The nurse should immediately follow up with the client with which ECG strip?
- A. QSTN 8-A.png
- B. QSTN 8-B.png
- C. QSTN 8-C.png
- D. QSTN 8-D.png
Correct Answer: A
Rationale: Without specific ECG details, the nurse prioritizes the strip indicating life-threatening arrhythmias (e.g., ventricular tachycardia or fibrillation) requiring immediate intervention.