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Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease?
- A. Assess the client's radial pulse.
- B. Assess the client's serum potassium level.
- C. Assess the client's glucometer reading.
- D. Assess the client's pulse oximeter reading.
Correct Answer: B
Rationale: Loop diuretics cause hypokalemia, which can precipitate dysrhythmias in CAD. Assessing potassium (B) is critical. Pulse (A), glucose (C), and SpO2 (D) are less directly related.
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Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy?
- A. Heart failure.
- B. Activity intolerance.
- C. Powerlessness.
- D. Anticipatory grieving.
Correct Answer: A
Rationale: Cardiomyopathy impairs cardiac function, leading to heart failure (A) as the primary medical problem. Activity intolerance (B), powerlessness (C), and grieving (D) are secondary psychosocial issues.
The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?
- A. The client with three (3) unifocal PVCs in one (1) minute.
- B. The client diagnosed with coronary artery disease who wants to ambulate.
- C. The client diagnosed with mitral valve prolapse with an audible S3.
- D. The client diagnosed with pericarditis who is in normal sinus rhythm.
Correct Answer: C
Rationale: An S3 in mitral valve prolapse (C) suggests heart failure, requiring immediate assessment. Unifocal PVCs (A) are less urgent, ambulation (B) is routine, and normal rhythm in pericarditis (D) is stable.
The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement?
- A. Administer the medication as ordered.
- B. Prepare to administer vitamin K (AquaMephyton).
- C. Hold the medication and notify the HCP.
- D. Assess the client for abnormal bleeding.
Correct Answer: A
Rationale: INR 2.7 (A) is within the therapeutic range (2–3) for mechanical valves, so administer warfarin. Vitamin K (B) reverses anticoagulation, holding (C) is unnecessary, and bleeding (D) is routine but not primary.
Which population is at a higher risk for dying from a myocardial infarction?
- A. Caucasian males.
- B. Hispanic females.
- C. Asian males.
- D. African American females.
Correct Answer: D
Rationale: African American females (D) have higher MI mortality rates due to increased prevalence of risk factors like hypertension and diabetes, and disparities in healthcare access. Caucasian males (A), Hispanic females (B), and Asian males (C) have lower relative risk.
The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of 'decreased cardiac output related to inability of the heart to pump effectively' is written. Which short-term goal would be best for the client?
- A. The client will be able to ambulate in the hall by date of discharge.
- B. The client will have an audible S1 and S2 with no S3 heard by end of shift.
- C. The client will turn, cough, and deep breathe every two (2) hours.
- D. The client will have a SaO2 reading of 98% by day two (2) of care.
Correct Answer: B
Rationale: Absence of an S3 heart sound (B) indicates improved cardiac function, directly addressing decreased cardiac output. Ambulation (A) is long-term, turning/coughing (C) is an intervention, and SaO2 of 98% (D) is less specific to cardiac output.