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Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply.
- A. Paroxysmal nocturnal dyspnea.
- B. Orthopnea.
- C. Cough.
- D. Pericardial friction rub.
- E. Pulsus paradoxus.
Correct Answer: A,B,C
Rationale: Valvular disease causes fluid overload, leading to PND (A), orthopnea (B), and cough (C). Pericardial rub (D) and pulsus paradoxus (E) are specific to pericarditis/tamponade.
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The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor?
- A. The client admitted for diagnostic tests to rule out valvular heart disease.
- B. The client three (3) days post-myocardial infarction being discharged tomorrow.
- C. The client exhibiting supraventricular tachycardia (SVT) on telemetry.
- D. The client diagnosed with atrial fibrillation who has an INR of five (5).
Correct Answer: A
Rationale: Diagnostic testing for valvular disease (A) is stable, suitable for a new graduate. Post-MI (B), SVT (C), and high INR (D) require experienced care.
Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply.
- A. Encourage a low-fat, low-cholesterol diet.
- B. Instruct the client to walk 30 minutes a day.
- C. Decrease the salt intake to two (2) g a day.
- D. Refer to a counselor for stress reduction techniques.
- E. Teach the client to increase fiber in the diet.
Correct Answer: A,B,D,E
Rationale: Low-fat/cholesterol diet (A), walking (B), stress reduction (D), and high-fiber diet (E) reduce CAD risk. Salt restriction (C) is more specific to CHF or hypertension.
The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse?
- A. The client's BP is 110/70 and pulse is 90.
- B. The client's groin dressing is dry and intact.
- C. The client refuses to keep the leg straight.
- D. The client denies any numbness and tingling.
Correct Answer: C
Rationale: Refusing to keep the leg straight (C) risks bleeding from the femoral site, requiring immediate intervention. Normal BP/pulse (A), intact dressing (B), and no numbness (D) are expected.
The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?
- A. Administer sublingual nitroglycerin.
- B. Obtain a STAT electrocardiogram (ECG).
- C. Have the client sit down immediately.
- D. Assess the client's vital signs.
Correct Answer: C
Rationale: Activity-related chest pain suggests ischemia. Having the client sit (C) stops exertion, reducing oxygen demand. Nitroglycerin (A), ECG (B), and vital signs (D) follow.
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
- A. Assist the client to go down to the smoking area for a cigarette.
- B. Transport the client to the intensive care unit (ICU) via a stretcher.
- C. Provide the client going home discharge-teaching instructions.
- D. Help position the client who is having a portable x-ray done.
Correct Answer: D
Rationale: Positioning for an x-ray (D) is within the UAP’s scope and safe. Smoking (A) is inappropriate, ICU transport (B) requires nursing judgment, and discharge teaching (C) is a nursing responsibility.