Nokea
The nurse observes sinus tachycardia with new-onset ST segment elevation on the ECG monitor of the client reporting chest pain. Which should be the nurse’s priority intervention?
- A. Draw blood for cardiac enzymes STAT
- B. Call the cardiac catheterization laboratory
- C. Apply 1 inch of nitroglycerin paste topically
- D. Apply 4 liters of oxygen via nasal cannula
Correct Answer: D
Rationale: The nurse’s priority intervention should be to increase oxygen to the heart muscle. Applying 4 liters of oxygen via nasal cannula addresses the immediate need to improve myocardial oxygenation in an evolving MI indicated by ST elevation. Cardiac enzymes, catheterization, and nitroglycerin are secondary actions.
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The nurse is assessing the client. At which area should the nurse place the stethoscope to best auscultate the client’s murmur associated with mitral regurgitation?
- A. Line A
- B. Line B
- C. Line C
- D. Line D
Correct Answer: D
Rationale: Mitral regurgitation is heard at the location of the mitral valve (line D) and should be auscultated with the bell of the stethoscope at the fifth intercostal space, left midclavicular line. The bell is used to auscultate low-pitched sounds. Lines A, B, and C correspond to aortic, pulmonic, and tricuspid valves, respectively.
The nurse who is beginning a shift on a cardiac step-down unit receives shift report for four clients. Prioritize the order, from most urgent to least urgent, that the nurse should assess the clients.
- A. The 56-year-old client who was admitted 1 day ago with chest pain receiving intravenous (IV) heparin and has a partial thromboplastin time (PTT) due back in 30 minutes
- B. The 62-year-old client with end-stage cardiomyopathy, blood pressure (BP) of 78/50 mm Hg, 20 mL/hr urine output, and a “Do Not Resuscitate” order; whose family has just arrived
- C. The 72-year-old client who was transferred 2 hours ago from the intensive care unit (ICU) following a coronary artery bypass graft and has new-onset atrial fibrillation with rapid ventricular response
- D. The 38-year-old postoperative client who had an aortic valve replacement 2 days ago, BP 114/72 mm Hg, heart rate (HR) 100 beats/min, respiratory rate (RR) 28 breaths/min, and temperature 101.2°F (38.4°C)
Correct Answer: C;D;A;B
Rationale: The nurse should assess: C) Atrial fibrillation with rapid ventricular response is life-threatening; D) Elevated temperature and vital signs suggest infection; A) Heparin adjustment is pending but less urgent; B) End-stage cardiomyopathy with DNR is stable and family support is secondary.
The client with symptoms of intermittent claudication receives treatment with a peripheral percutaneous transluminal angioplasty procedure with placement of an endovascular stent. Which statements, if made by the client, support the home-care nurse’s conclusion that the client is making lifestyle changes to decrease the likelihood of restenosis and arterial occlusion? Select all that apply.
- A. “I have been doing exercises twice daily.”
- B. “All nicotine products were thrown away.”
- C. “These support hose keep my legs warm.”
- D. “I see a podiatrist tomorrow for foot care.”
- E. “I'm following a low-saturated-fat diet”
- F. “I now take rosuvastatin calcium.”
Correct Answer: A;B;E;F
Rationale: The client’s statements indicating lifestyle changes are: A) Exercising to promote collateral circulation; B) Discontinuing nicotine to deter atherosclerosis; E) Following a low-saturated-fat diet to reduce atherosclerosis; F) Taking rosuvastatin to lower cholesterol. Support hose and podiatry care do not directly prevent restenosis.
The nurse is discussing healthy lifestyle practices with the client who has chronic venous insufficiency. Which practices should be emphasized with this client? Select all that apply.
- A. Avoid eating an excess of dark green vegetables.
- B. Take rests and elevate the legs while sitting.
- C. Wear graduated compression stockings, removing them at night.
- D. Increase standing time and shift weight when upright.
- E. Sleep with legs elevated above the level of the heart.
Correct Answer: B;C;E
Rationale: The nurse should emphasize: B) Elevating legs when sitting to promote venous return; C) Wearing compression stockings to reduce edema; E) Sleeping with legs elevated to enhance venous return. Avoiding dark green vegetables is relevant only with anticoagulants, and prolonged standing should be avoided.
The nurse collects the following assessment data on the client who has no known health problems: BP 135/89 mm Hg; BMI 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum potassium 4.0 mEq/L; LDL cholesterol 200 mg/dL; HDL cholesterol 25 mg/dL; and triglycerides 180 mg/dL. Which intervention should the nurse anticipate?
- A. A low-calorie regular diet
- B. A statin antilipidemic medication
- C. A thiazide diuretic medication
- D. Low-salt, low-saturated-fat, low-potassium diet
Correct Answer: B
Rationale: A statin antilipidemic should be prescribed to manage the client’s hypercholesterolemia. It will lower the LDL cholesterol and triglycerides and increase the HDL cholesterol. A low-calorie diet is unnecessary with a normal BMI, a diuretic is not indicated for slightly elevated BP, and a low-potassium diet is not needed with normal potassium levels.