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 with an anterior-lateral MI. The nurse should add decreased cardiac output to the client’s plan of care when which finding is noted?
- A. Pain radiates up left arm to neck
- B. Presence of an S4 heart sound
- C. Crackles auscultated in both lung bases
- D. Vesicular breath sounds over lung lobes
Correct Answer: C
Rationale: An anterior-lateral MI can produce left ventricular dysfunction and low cardiac output. With decreased cardiac output, blood accumulates in the heart and backs up into the pulmonary system, causing fluid to move into interstitial spaces and alveoli, resulting in crackles. Pain radiation, S4 sounds, and vesicular breath sounds do not directly indicate decreased cardiac output.
While preparing the client for a computed tomography angiography (CTA), the client asks the nurse what the test Will entail. Which should be the nurse’s correct response?
- A. “A CTA uses magnetic fields to visualize the major vessels Within your body.”
- B. “A CTA is an invasive procedure that requires a small incision into an artery.”
- C. “A CTA is a quick procedure that requires anesthesia for about 20 minutes.”
- D. “A CTA is a scan that includes a contrast dye injection to visualize your arteries.”
Correct Answer: D
Rationale: The correct response should explain CTA. CTA is a noninvasive spiral CT scan using contrast dye to yield a 3-dimensional image of the arteries. It does not use magnetic fields (A), require incisions (B), or anesthesia (C).
The nurse obtains the client’s cardiac monitor print-out illustrated. What should be the nurse’s interpretation of the client’s rhythm?
- A. Atrial flutter
- B. Atrial fibrillation
- C. Sinus bradycardia
- D. Sinus rhythm with premature atrial contractions (PACs)
Correct Answer: C
Rationale: Sinus bradycardia is a regular rhythm with a ventricular rate less than 60 bpm and one discernable P wave prior to each QRS. Atrial flutter and fibrillation have multiple or nondiscernible P waves, and PACs include premature atrial beats, which are not described in the image.
The nurse is completing a home visit with the client who has an arterial ulcer secondary to PAD. Which statement by the client warrants immediate intervention by the nurse?
- A. “I soak my feet daily to warm them and keep them soft.”
- B. “I cover the sore on my foot with sterile gauze to protect it.”
- C. “I use a pillow under my calves to keep my heels off the bed.”
- D. “I lubricate my feet daily to prevent them from cracking.”
Correct Answer: A
Rationale: The nurse should immediately intervene when the client states soaking feet daily; foot soaks when the client has PAD can cause maceration (tissue breakdown). Covering with gauze, using a pillow, and lubricating are appropriate actions.
The nurse is giving discharge teaching to the client following aortic valve replacement surgery with a synthetic valve. The nurse evaluates that the client understands the teaching when the client states plans to take which action? Select all that apply.
- A. Use a soft toothbrush for dental hygiene.
- B. Floss teeth daily to prevent plaque.
- C. Wear loose-fitting T-shirts or tops.
- D. Use an electric razor for shaving.
- E. Consume foods high in vitamin K.
Correct Answer: A;C;D
Rationale: The client understands when stating: A) Using a soft toothbrush to reduce bleeding risk on anticoagulants; C) Wearing loose-fitting clothing to avoid incision friction; D) Using an electric razor to prevent cuts. Flossing (B) increases bleeding and endocarditis risk, and high vitamin K (E) antagonizes anticoagulants.