Nokea
Which of the following electrocardiogram (ECG) changes supports the diagnosis that the client is experiencing a myocardial infarction (MI)?
- A. Inverted P wave
- B. Prolonged PR interval
- C. Widened QRS complex
- D. Elevated ST segment
Correct Answer: D
Rationale: ST-segment elevation on ECG is a hallmark of acute myocardial infarction, indicating myocardial ischemia.
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Using the following cardiac structures, trace the normal stress in which blood circulates on the left side of the heart. Use all the options.
- A. Aorta
- B. Left ventricle
- C. Pulmonary veins
- D. Left atrium
- E. Mitral valve (correct sequence: 3, 4, 5, 2, 1)
Correct Answer: D
Rationale: Blood flows: pulmonary veins → left atrium → mitral valve → left ventricle → aorta.
The nurse identifies the concept of perfusion for a client diagnosed with congestive heart failure. Which assessment data support this concept?
- A. The client has a large abdomen and a positive tympanic wave.
- B. The client has paroxysmal nocturnal dyspnea.
- C. The client has 2+ glucose in the urine.
- D. The client has a comorbid condition of myocardial infarction.
Correct Answer: B
Rationale: PND (B) indicates fluid overload in CHF, supporting impaired perfusion. Large abdomen (A) suggests ascites, glucosuria (C) is diabetes-related, and MI (D) is a cause, not a symptom.
The nurse assessing the client with pericardial effusion at 1600 notes the apical pulse is 72 and the BP is 138/94. At 1800, the client has neck vein distention, the apical pulse is 70, and the BP is 106/94. Which action would the nurse implement first?
- A. Stay with the client and use a calm voice.
- B. Notify the health-care provider immediately.
- C. Place the client left lateral recumbent.
- D. Administer morphine intravenous push slowly.
Correct Answer: B
Rationale: JVD and hypotension (BP drop to 106/94) suggest cardiac tamponade; notifying the HCP (B) is urgent. Staying calm (A), lateral position (C), and morphine (D) are secondary.
An adult is admitted with venous thromboembolism. What treatment should the nurse expect during the acute stage?
- A. Application of an elastic stocking
- B. Ambulation three times a day
- C. Passive range of motion exercises to the legs
- D. Use of ice packs to control pain
Correct Answer: A
Rationale: Elastic stockings promote venous return and reduce swelling in the acute stage of venous thromboembolism. Ambulation, passive exercises, or ice packs may increase risk or be less effective.
Which nursing action is most appropriate when applying a new transdermal patient?
- A. Rotate the application site.
- B. Clean the skin with alcohol.
- C. Tape the patch to the client's chest.
- D. Take the blood pressure afterward.
Correct Answer: A
Rationale: Rotating the application site for a nitroglycerin patch prevents skin irritation and ensures consistent drug absorption.