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Which of the following findings would the nurse expect to observe in a client who has developed cardiac tamponade? Select all that apply.
- A. Unilateral crackles
- B. Systolic murmur
- C. Bradycardia
- D. Jugular venous distention
- E. Hypotension
Correct Answer: D,E
Rationale: Unilateral crackles suggest pulmonary issues, not tamponade. B: Incorrect - Systolic murmur is not specific to tamponade. C: Incorrect - Tachycardia, not bradycardia, is typical in tamponade due to compensatory mechanisms. D: Correct - Jugular venous distention occurs due to increased venous pressure. E: Correct - Hypotension results from reduced cardiac output in tamponade.
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The nurse is caring for a client with the below tracing on the electrocardiogram (ECG). The nurse should anticipate which prescription from the primary healthcare provider (PHCP)?
- A. captopril
- B. atropine
- C. adenosine
- D. diltiazem
Correct Answer: B
Rationale: Atropine is used to treat bradycardia, which may be indicated by certain ECG tracings showing slow heart rates. Captopril is an ACE inhibitor for hypertension or heart failure, adenosine is used for supraventricular tachycardia, and diltiazem is a calcium channel blocker for rate control in atrial arrhythmias.
A 45-year-old client is admitted to the medical telemetry unit to observe for possible dysrhythmias. After waking in the morning, the client asks the nurse for coffee. Which of the following would be the best response by the nurse?
- A. Hot beverages are not allowed because of the condition of your heart.
- B. Coffee is not included in your diet ordered by your health care provider (HCP).
- C. We don't have coffee on the unit. I can bring you some tea if you would like.
- D. Currently, you cannot have coffee as it contains caffeine, which can adversely affect your heart.
Correct Answer: D
Rationale: Caffeine can exacerbate dysrhythmias by stimulating the heart, making it contraindicated in this context.
The nurse assists the code team with an unresponsive and pulseless client. Which intervention does the nurse prepare for based on the electrocardiogram (ECG) tracing? See the image below.
- A. Prepare an infusion of sodium bicarbonate
- B. Administer epinephrine
- C. Defibrillation
- D. Cardioversion
Correct Answer: C
Rationale: Defibrillation is the treatment for pulseless ventricular fibrillation or ventricular tachycardia, per ACLS guidelines.
The nurse is discharging a client with heart failure who is prescribed digoxin and furosemide. Which of the following laboratory tests must the client have monitored due to this combination of prescribed medications?
- A. Fecal occult blood
- B. Serum electrolytes
- C. Urinalysis
- D. Glycosylated hemoglobin
Correct Answer: B
Rationale: Furosemide can cause hypokalemia, increasing digoxin toxicity risk, so serum electrolytes (especially potassium) must be monitored.
While auscultating a client's bowel sounds, the nurse notes a swooshing sound to the left of the umbilical area. What would be the nurse's priority action?
- A. Percuss over the area to assess for dullness
- B. Notify the primary healthcare provider (PHCP)
- C. Gently palpate the abdomen to assess for tenderness
- D. Ask the client about recent bowel movements
Correct Answer: B
Rationale: A swooshing sound may indicate an abdominal aortic aneurysm, a life-threatening condition requiring immediate PHCP notification.