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Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?
- A. Pulmonary embolus (PE).
- B. Cerebrovascular accident.
- C. Hemoptysis.
- D. Deep vein thrombosis.
Correct Answer: B
Rationale: Mitral valve vegetations can embolize to the brain, causing a stroke (B). PE (A) is right-sided, hemoptysis (C) is not typical, and DVT (D) is unrelated to embolization.
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The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client?
- A. Social worker.
- B. Physical therapy.
- C. Cardiac rehabilitation.
- D. Occupational therapy.
Correct Answer: C
Rationale: Cardiac rehabilitation (C) promotes recovery through exercise and education post-MI. Social work (A), physical therapy (B), and occupational therapy (D) are less specific.
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.
The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective?
- A. The client's peripheral pitting edema has gone from 3+ to 4+.
- B. The client is able to take the radial pulse accurately.
- C. The client is able to perform ADLs without dyspnea.
- D. The client has minimal jugular vein distention.
Correct Answer: C,D
Rationale: Effective CHF treatment reduces fluid overload, allowing ADLs without dyspnea (C) and minimal JVD (D). Increased edema (A) indicates worsening, and pulse-taking (B) is a skill, not a treatment outcome.
The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply.
- A. Monitor vital signs every 15 minutes for the first hour.
- B. Assess the client's heart and lung sounds.
- C. Record the amount of fluid removed as output.
- D. Evaluate the client's cardiac rhythm.
- E. Keep the client in the supine position.
Correct Answer: A,B,C,D
Rationale: Post-pericardiocentesis, monitor vital signs (A), heart/lung sounds (B), fluid output (C), and rhythm (D) to detect complications. Supine position (E) is not required; semi-Fowler’s is preferred.
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.