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The nurse observes that the client, 3 days post MI, seems unusually fatigued. Upon assessment, the client is dyspneic with activity, has sinus tachycardia, and has generalized edema. Which action by the nurse is most appropriate?
- A. Administer high-flow oxygen.
- B. Encourage the client to rest more.
- C. Continue to monitor the client’s heart rhythm.
- D. Compare the client’s admission and current weight.
Correct Answer: D
Rationale: A complication of MI is HF. Signs of HF include fatigue, dyspnea, tachycardia, edema, and weight gain. Comparing admission and current weight assesses fluid retention, a key indicator of HF severity. High-flow oxygen is unnecessary without hypoxia, rest alone won’t address HF, and monitoring rhythm delays intervention.
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The client, who is a 15-pack-year cigarette smoker, has painful fingers and toes and is diagnosed with Buerger’s disease (thromboangiitis obliterans). Which measure to prevent disease progression should be the nurse’s initial focus when teaching the client?
- A. Avoid exposure to cold temperatures
- B. Maintain meticulous hygiene
- C. Abstain from all tobacco products
- D. Follow a low-saturated-fat diet
Correct Answer: C
Rationale: Buerger’s disease is an uncommon vascular occlusive disease that affects the medial and small arteries and veins, initially in the distal limbs. It is strongly associated with tobacco use, which causes vasoconstriction. The most important action to communicate to the client is that he must abstain from tobacco in all forms to prevent progression of the disease.
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.
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 admitting the client with a thoracic aortic aneurysm. Which intervention should the nurse plan to include?
- A. Administering antihypertensive medications
- B. Palpating the abdomen to determine the aneurysm’s size
- C. Inserting a nasogastric tube set to moderate suction
- D. Teaching about a diet high in potassium and low in sodium
Correct Answer: A
Rationale: The nurse should include administering antihypertensive medications to the client with a thoracic aortic aneurysm; controlling HR and BP is important to decrease the risk of aneurysm rupture. Palpation is contraindicated, and NG tubes or specific diets are not indicated.
The nurse, assessing the client hospitalized following an MI, obtains these VS: BP 78/38 mm Hg, HR 128, RR 32. The nurse notifies the HCP concerned that the client may be experiencing which most life-threatening complication?
- A. Pulmonary embolism
- B. Cardiac tamponade
- C. Cardiomyopathy
- D. Cardiogenic shock
Correct Answer: D
Rationale: The symptoms are indicative of cardiogenic shock (decreased cardiac output leading to inadequate tissue perfusion and initiation of the shock syndrome). Pulmonary embolism and tamponade could cause shock but are less likely post-MI, and cardiomyopathy is not an acute complication.