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Which of the following should the nurse do for a client reporting chest pain radiating to the arm? Select all that apply.
- A. Obtain an electrocardiogram (ECG)
- B. Prepare the client for cardioversion
- C. Establish intravenous (IV) access
- D. Insert an indwelling urinary catheter
- E. Administer prescribed nitroglycerin
Correct Answer: A,C,E
Rationale: ECG is critical to diagnose the cause of chest pain. B: Incorrect - Cardioversion is for specific arrhythmias, not chest pain alone. C: Correct - IV access is needed for potential medications. D: Incorrect - Urinary catheter is not indicated for chest pain. E: Correct - Nitroglycerin relieves ischemic chest pain.
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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.
Which of the following statements about sodium are true for a client newly diagnosed with hypertension? Select all that apply.
- A. Sodium cannot be completely eliminated from the diet.
- B. There is no sodium in fresh fruits and vegetables.
- C. Canned vegetables should be avoided.
- D. The body needs some sodium as it plays an important role in water balance.
- E. Reduce daily sodium intake to 2,000 mg
Correct Answer: A,C,D
Rationale: Sodium is naturally present in many foods, making complete elimination impossible. B: Incorrect - Fresh fruits and vegetables contain small amounts of sodium naturally. C: Correct - Canned vegetables are high in sodium and should be avoided or rinsed. D: Correct - Sodium is essential for fluid balance and nerve function. E: Incorrect - Guidelines recommend reducing sodium to 1,500 mg/day for hypertension, not 2,000 mg.
History of Present Illness (HPI)
The client was found disoriented upon arrival and in acute respiratory distress.
The client's caregiver noted that the prescribed medications had not been
taken for several days. Medical history includes hypertension, diabetes mellitus,
congestive heart failure, and arthritis. Client Assessment Bounding peripheral pulses,
normotensive, crackles in the lung fields, tachypnea, jugular venous distention, and
abdominal distention.
Diagnosis
1. Pulmonary edema
2. Acute decompensated heart failure
Based on the clinical data, which prescription would the nurse request from the primary healthcare provider for a client with pulmonary edema and acute decompensated heart failure? Select all that apply.
- A. Albuterol
- B. Hydrocortisone
- C. Diltiazem
- D. Nitroglycerin
- E. Furosemide
Correct Answer: D,E
Rationale: Albuterol is for bronchospasm, not pulmonary edema. B: Incorrect - Hydrocortisone is not indicated for heart failure. C: Incorrect - Diltiazem is for rate control, not fluid overload. D: Correct - Nitroglycerin reduces preload, alleviating pulmonary edema. E: Correct - Furosemide is a diuretic to reduce fluid overload.
An emergency department nurse is caring for a client who presented with fatigue, muscular weakness, and dyspnea. Upon assessment, the client was noted to be coughing frequently and sitting in a tripod position. A subsequent diagnosis of left ventricular failure was made. The nurse understands that manifestations of left-sided heart failure present as respiratory issues because:
- A. There is venous congestion in the liver.
- B. There is hypoperfusion of tissue cells.
- C. There is pulmonary congestion.
- D. Despite normal cardiac output, the heart cannot meet the accelerated demands of the body.
Correct Answer: C
Rationale: Left-sided heart failure causes pulmonary congestion, leading to respiratory symptoms like dyspnea and cough.
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.