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The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first?
- A. The client diagnosed with myocardial infarction who has an audible S3 heart sound.
- B. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema.
- C. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%.
- D. The client with chronic renal failure who has an elevated creatinine level.
Correct Answer: A
Rationale: An S3 heart sound post-MI (A) indicates heart failure or fluid overload, requiring immediate assessment. Edema (B) is chronic, 94% SpO2 (C) is stable, and elevated creatinine (D) is expected in CRF.
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The client diagnosed with an ST elevation myocardial infarction (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which should the nurse implement first?
- A. Notify the health care provider (HCP).
- B. Assess what the client ate at the last meal.
- C. Request a STAT 12 lead electrocardiogram.
- D. Administer furosemide IVP.
Correct Answer: A
Rationale: Edema and crackles post-STEMI suggest heart failure; notifying the HCP (A) ensures timely intervention. Diet (B), ECG (C), and furosemide (D) follow HCP orders.
The nurse is assisting with a synchronized cardioversion on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take?
- A. Wait until the machine discharges.
- B. Shout 'all clear' and don’t touch the bed.
- C. Make sure the client is all right.
- D. Increase the joules and redischarge.
Correct Answer: A
Rationale: A pause in synchronized cardioversion is normal as the machine syncs with the QRS complex; wait for discharge (A). 'All clear' (B) is for defibrillation, checking client (C) is premature, and increasing joules (D) is incorrect.
The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse?
- A. Muffled heart sounds.
- B. Nondistended jugular veins.
- C. Bounding peripheral pulses.
- D. Pericardial friction rub.
Correct Answer: A
Rationale: Muffled heart sounds (A) suggest cardiac tamponade, a life-threatening complication requiring immediate attention. Non-distended JVD (B) is normal, bounding pulses (C) are unrelated, and friction rub (D) is expected.
The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first?
- A. Administer oxygen via nasal cannula.
- B. Evaluate the client's urinary output.
- C. Assess the client for cardiac complications.
- D. Encourage the client to use the incentive spirometer.
Correct Answer: C
Rationale: Increased pain in pericarditis may indicate complications like tamponade. Assessing for cardiac complications (C) is the priority. Oxygen (A), urinary output (B), and spirometry (D) are secondary.
The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the Post Anesthesia Care Unit nurse implement?
- A. Assess the client's chest tube output.
- B. Monitor the client's chest dressing.
- C. Evaluate the client's endotracheal (ET) lip line.
- D. Keep the client's affected leg straight.
Correct Answer: D
Rationale: Valvuloplasty is performed via femoral access, so keeping the leg straight (D) prevents bleeding. Chest tubes (A), dressings (B), and ET tubes (C) are not involved.