Nokea
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.
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The nurse is to administer 40 mg of furosemide to the client in HF. The prefilled syringe reads 100 mg/mL. In order to give the correct dose, how many milliliters should the nurse administer to the client?
Correct Answer: 0.4
Rationale: Use a proportion formula: 100 mg: 1 mL :: 40 mg: X mL; 100X = 40; X = 0.4. The nurse should administer 0.4 mL of furosemide.
The nurse is assessing the client who underwent repair of an aortic aneurysm with graft placement 30 minutes ago. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. What should be the nurse’s priority?
- A. Recheck the pulse in 5 minutes.
- B. Reposition the affected leg.
- C. Notify the surgeon of the finding.
- D. Document that the pulse is absent.
Correct Answer: C
Rationale: The nurse should notify the surgeon immediately to reassess the client. The loss of the pulse could signify graft occlusion or embolization. Rechecking, repositioning, or documenting delays critical intervention.
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.
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 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.