Nokea
Which action should the nurse prepare to take for a client experiencing a myocardial infarction? Select all that apply.
- A. Start a peripheral vascular access device (VAD)
- B. Obtain a prescription for albuterol via nebulizer
- C. Obtain a prescription for chewable aspirin
- D. Obtain a prescription for nitroglycerin
- E. Obtain an order for a chest radiograph (x-ray)
- F. Establish continuous cardiac monitoring
Correct Answer: A,C,D,F
Rationale: IV access is needed for medications. B: Incorrect - Albuterol is for respiratory issues, not MI. C: Correct - Aspirin reduces clot formation. D: Correct - Nitroglycerin relieves chest pain and reduces preload. E: Incorrect - Chest X-ray is not a priority in acute MI. F: Correct - Cardiac monitoring detects arrhythmias.
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A client is being discharged following the insertion of a permanent pacemaker. Which of the following should be included in the client's discharge instructions?
- A. Air travel will not be possible due to airport screening equipment.
- B. You will need to discard any radios at home that have antennas.
- C. Computed tomography (CT) scans are not permitted with this device.
- D. You should use your cellular phone on the opposite side of the generator.
Correct Answer: D
Rationale: Using a cell phone on the opposite side of the pacemaker reduces electromagnetic interference.
The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The nurse identifies this tracing as
- A. sinus tachycardia.
- B. supraventricular tachycardia.
- C. ventricular tachycardia.
- D. atrial flutter.
Correct Answer: C
Rationale: Ventricular tachycardia is a life-threatening arrhythmia requiring immediate intervention, characterized by wide QRS complexes on ECG.
The nurse is planning care for a client admitted with infective endocarditis (IE). Which assessment finding would indicate that the client is experiencing a complication?
- A. petechial rashes
- B. flank pain
- C. headache
- D. fever
Correct Answer: B
Rationale: Flank pain may indicate renal embolism, a complication of infective endocarditis due to septic emboli.
The nurse is caring for a client who appears to be developing heart failure (HF). Which of the following laboratory tests would the nurse expect the primary health care provider (PHCP) to prescribe to confirm the diagnosis?
- A. Basic metabolic panel (BMP)
- B. B-type natriuretic peptide (BNP)
- C. Lipid profile
- D. Troponin
Correct Answer: B
Rationale: BNP is a specific biomarker elevated in heart failure, reflecting ventricular stress and fluid overload.
Which of the following statements should the nurse include when teaching a community health course on adult cardiopulmonary resuscitation (CPR)? Select all that apply.
- A. The compression rate is 100 to 120 per minute.
- B. The compression depth should be 1.5 inches.
- C. Allow full chest recoil between compressions.
- D. Rotate compressor at least every 2 minutes.
- E. Stop to check your pulse every 30 seconds.
Correct Answer: A,C,D
Rationale: Compression rate of 100-120/min ensures adequate circulation. B: Incorrect - Depth should be 2-2.4 inches in adults. C: Correct - Full chest recoil maximizes venous return. D: Correct - Rotating compressors prevents fatigue. E: Incorrect - Pulse checks are done after rhythm checks, not every 30 seconds.