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Which meal would indicate the client understands the discharge teaching concerning the recommended diet for coronary artery disease?
- A. Baked fish, steamed broccoli, and garden salad.
- B. Enchilada dinner with fried rice and refried beans.
- C. Tuna salad sandwich on white bread and whole milk.
- D. Fried chicken, mashed potatoes, and gravy.
Correct Answer: A
Rationale: Baked fish, steamed broccoli, and salad (A) are low-fat and heart-healthy, aligning with CAD diet teaching. Enchiladas (B), tuna with whole milk (C), and fried chicken (D) are high in fat/sodium.
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The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first?
- A. Administer oxygen via nasal cannula.
- B. Evaluate the client's urinary output.
- C. Assess the client for cardiac complications.
- D. Encourage the client to use the incentive spirometer.
Correct Answer: C
Rationale: Increased pain in pericarditis may indicate complications like tamponade. Assessing for cardiac complications (C) is the priority. Oxygen (A), urinary output (B), and spirometry (D) are secondary.
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.
Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation?
- A. Defibrillate the client at 50, 100, and 200 joules.
- B. Do not remove the oxygen source during defibrillation.
- C. Place petroleum jelly on the defibrillator pads.
- D. Shout 'all clear' prior to defibrillating the client.
Correct Answer: D
Rationale: Shouting 'all clear' (D) ensures safety before defibrillation. Energy levels (A) are 200–360 joules, oxygen (B) is removed to prevent fire, and petroleum jelly (C) is not used.
Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet?
- A. I will not eat more than six (6) eggs a week.'
- B. I should bake or grill any meats I eat.'
- C. I will drink eight (8) ounces of whole milk a day.'
- D. I should not eat any type of pork products.'
Correct Answer: B
Rationale: Baking or grilling meats (B) reduces fat, aligning with a low-fat CAD diet. Six eggs (A) are excessive, whole milk (C) is high-fat, and avoiding pork (D) is overly restrictive.
The client shows ventricular fibrillation on the telemetry at the nurse’s station. Which action should the telemetry nurse implement first?
- A. Administer epinephrine IVP.
- B. Prepare to defibrillate the client.
- C. Call a STAT code.
- D. Start cardiopulmonary resuscitation (CPR).
Correct Answer: C
Rationale: Ventricular fibrillation is a code situation. Calling a STAT code (C) initiates the response team. Epinephrine (A), defibrillation (B), and CPR (D) follow code activation.