Nokea
The unlicensed assistive personnel (UAP) tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first?
- A. Tell the UAP to go take the client's vital signs.
- B. Ask the UAP to have the telemetry nurse read the strip.
- C. Notify the client's health-care provider.
- D. Go to the room and assess the client's chest pain.
Correct Answer: D
Rationale: Chest pain in CAD requires immediate nurse assessment (D) to determine severity and cause. Vital signs (A), telemetry (B), and notifying HCP (C) follow assessment.
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The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor?
- A. The client admitted for diagnostic tests to rule out valvular heart disease.
- B. The client three (3) days post-myocardial infarction being discharged tomorrow.
- C. The client exhibiting supraventricular tachycardia (SVT) on telemetry.
- D. The client diagnosed with atrial fibrillation who has an INR of five (5).
Correct Answer: A
Rationale: Diagnostic testing for valvular disease (A) is stable, suitable for a new graduate. Post-MI (B), SVT (C), and high INR (D) require experienced care.
Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply.
- A. Paroxysmal nocturnal dyspnea.
- B. Orthopnea.
- C. Cough.
- D. Pericardial friction rub.
- E. Pulsus paradoxus.
Correct Answer: A,B,C
Rationale: Valvular disease causes fluid overload, leading to PND (A), orthopnea (B), and cough (C). Pericardial rub (D) and pulsus paradoxus (E) are specific to pericarditis/tamponade.
The nurse has written an outcome goal 'demonstrates tolerance for increased activity' for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome?
- A. Measure intake and output.
- B. Provide two (2)g sodium diet.
- C. Weigh the client daily.
- D. Plan for frequent rest periods.
Correct Answer: D
Rationale: Frequent rest periods (D) prevent overexertion, supporting activity tolerance in CHF. Intake/output (A), sodium diet (B), and daily weights (C) are important but less directly related to activity.
The client has an implantable cardioverter defibrillator (ICD). Which discharge instructions should the nurse teach the client?
- A. Do not lift or carry more than 23 kg.
- B. Have someone drive the car for the rest of your life.
- C. Carry the cell phone on the opposite side of the ICD.
- D. Avoid using the microwave oven in the home.
Correct Answer: C
Rationale: Carrying the cell phone on the opposite side (C) minimizes electromagnetic interference with the ICD. Lifting limits (A) are typically 10–15 lbs initially, driving (B) is restricted temporarily, and microwaves (D) are safe.
The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina?
- A. Put a nitroglycerin tablet under the tongue.
- B. Stop the activity immediately and rest.
- C. Document when and what activity caused angina.
- D. Notify the health-care provider immediately.
Correct Answer: B
Rationale: Stopping activity and resting (B) reduces oxygen demand, the first step in angina. Nitroglycerin (A) follows, documenting (C) is later, and notifying HCP (D) is for persistent pain.