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Where is the correct placement for the nurse's hands before administering cardiac compressions?
- A. On the lower half of the sternum
- B. On the lower half of the xiphoid process
- C. Over the costal cartilage
- D. Directly above the manubrium
Correct Answer: A
Rationale: Hands are placed on the lower half of the sternum (center of the chest) for effective CPR compressions.
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Which action by a newly hired nursing assistant indicates that the nurse needs to provide more instruction to the nursing assistant on how to accurately assess the client's pulse rate?
- A. The nursing assistant places a thumb over the radial artery.
- B. The nursing assistant counts the pulse rate for 1 full minute.
- C. The nursing assistant rests the client's arm on the abdomen.
- D. The nursing assistant presses the radial artery against the bone.
Correct Answer: A
Rationale: Using the thumb to check the pulse can result in counting the assistant's own pulse, leading to inaccurate readings.
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply.
- A. Administer morphine intramuscularly.
- B. Administer an aspirin orally.
- C. Apply oxygen via a nasal cannula.
- D. Place the client in a supine position.
- E. Administer nitroglycerin subcutaneously.
Correct Answer: B,C
Rationale: Aspirin (B) reduces clot formation, and oxygen (C) improves myocardial oxygenation. Morphine IM (A) delays absorption, supine position (D) increases preload, and nitroglycerin SC (E) is incorrect; SL is used.
Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)?
- A. Creatine kinase (CK-MB).
- B. Lactate dehydrogenase (LDH).
- C. Troponin.
- D. White blood cells (WBCs).
Correct Answer: C
Rationale: Troponin (C) rises within 3–4 hours post-MI, making it the earliest marker. CK-MB (A) rises in 4–6 hours, LDH (B) in 24–48 hours, and WBCs (D) are nonspecific.
The licensed practical nurse (LPN) is assisting the registered nurse (RN) in developing the nursing care plan for an older adult who has congestive heart failure. Which nursing diagnosis is most likely to be included?
- A. Deficient fluid volume
- B. Impaired verbal communication
- C. Chronic pain
- D. Activity intolerance
Correct Answer: D
Rationale: Activity intolerance is common in congestive heart failure due to reduced cardiac output and fatigue. Fluid volume excess, not deficit, is typical, and communication or pain are less likely.
A young adult with a history of rheumatic fever as a child is to have a cardiac catheterization. She asks the nurse why she must have a cardiac catheterization. The nurse's response is based on the understanding that cardiac catheterization can accomplish all of the following EXCEPT:
- A. assessing heart structures.
- B. determining oxygen levels in the heart chambers.
- C. evaluating cardiac output.
- D. obtaining a biopsy specimen.
Correct Answer: D
Rationale: Cardiac catheterization can assess heart structures, measure oxygen levels, and evaluate cardiac output, but obtaining a biopsy specimen is not a standard purpose of this procedure. Biopsies are typically performed via other methods, such as endomyocardial biopsy in specific cases.