Nokea
Which of the following statements by the client with atrial fibrillation would require a follow-up? Select all that apply.
- A. I have an increased risk for a stroke.
- B. I should weigh myself daily at the same time.
- C. I may be prescribed medications such as amiodarone.
- D. I should wear a mask when I am in public.
- E. I should seek medical care if I develop shortness of breath.
Correct Answer: B,D
Rationale: Atrial fibrillation increases stroke risk due to clot formation; no follow-up needed. B: Incorrect - Daily weighing is more relevant for heart failure, not atrial fibrillation; requires clarification. C: Correct - Amiodarone is a common medication for atrial fibrillation; no follow-up needed. D: Incorrect - Wearing a mask in public is not related to atrial fibrillation management; requires clarification. E: Correct - Shortness of breath could indicate complications; no follow-up needed.
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The nurse assesses a client three hours following cardiac surgery. Assessment findings were a blood pressure of 88/52 mm Hg, jugular venous distention, and muffled heart sounds. The nurse anticipates that this client will need an immediate
- A. thoracentesis.
- B. pericardiocentesis.
- C. arthrocentesis.
- D. paracentesis.
Correct Answer: B
Rationale: These findings suggest cardiac tamponade, requiring pericardiocentesis to remove fluid compressing the heart.
The nurse is caring for a client with the below tracing on the electrocardiogram. The nurse should perform which priority action? See the image below.
- A. initiate a code blue.
- B. establish a peripheral vascular access device
- C. notify the primary healthcare physician (PHCP)
- D. assess the client's airway, breathing, and circulation
Correct Answer: D
Rationale: For any critical ECG tracing (e.g., ventricular fibrillation), assessing airway, breathing, and circulation (ABCs) is the priority to guide further interventions.
Which of the following statements correctly outlines the proper flow of blood through the heart?
- A. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation
- B. Superior and Inferior vena cavas → Right atrium → Mitral valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Tricuspid valve → Left ventricle → Aortic valve → Aorta → Systemic circulation
- C. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary veins → Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation
- D. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Aortic valve → Pulmonary veins → Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Pulmonary valve → Aorta → Systemic circulation
Correct Answer: A
Rationale: This sequence accurately describes blood flow: deoxygenated blood enters the right heart, is pumped to the lungs, and oxygenated blood returns to the left heart for systemic circulation.
The nurse in the emergency department (ED) is assessing a client who may have an acute myocardial infarction. Which of the following findings would support this diagnosis?
- A. U-waves
- B. T-wave inversion
- C. ST-segment elevation
- D. Prolonged PR-interval
Correct Answer: C
Rationale: ST-segment elevation on ECG is a hallmark of acute myocardial infarction, indicating myocardial ischemia.
The nurse is caring for a client following a femoral angiography. When developing this client's plan of care, the nurse plans to
- A. encourage the client to ambulate within one hour following this procedure.
- B. discontinue prescribed intravenous fluids immediately after the procedure
- C. assess kidney function via lab testing on the day following the procedure.
- D. maintain nothing by mouth (NPO) status for 4 hours following the procedure.
Correct Answer: C
Rationale: Femoral angiography involves contrast dye, which can affect kidney function. Monitoring renal function via lab tests (e.g., creatinine) post-procedure is essential to detect contrast-induced nephropathy.