212 nclex questions
Which is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? The client: a) can perform personal self-care activities without pain. b) participates in a cardiac rehabilitation walking program. c) can identify risk factors for MI. d) continues to have severe chest pain.
a) can perform personal self-care activities without pain. Explanation: By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program.
A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." The CSU nurse should be especially observant for: a) dry mucous membranes. b) pulmonary crackles. c) high urine output. d) hypertension.
b) pulmonary crackles. Explanation: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren't directly associated with elevated pulmonary artery wedge pressures.
A client is admitted to the emergency department with sudden onset of chest pain. Which prescriptions should the nurse implement immediately? Select all that apply. a) Insert a Foley catheter. b) Administer aspirin. c) Administer nitroglycerin. d) Provide oxygen. e) Administer morphine. f) Administer acetaminophen
b)• Administer aspirin. C)• Administer nitroglycerin. d)• Provide oxygen. e)• Administer morphine. When emergently managing chest pain, the nurse can use the memory mnemonic MONA to plan care: morphine, oxygen, nitroglycerin, and aspirin. A Foley catheter is not included in the emergent management of chest pain and can be inserted when the pain has been relieved and the client is stable. Acetaminophen is not used to manage chest pain
A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which prescription from the health care provider should the nurse verify before implementing? a) Prepare for a pulmonary artery catheter insertion. b) Titrate dobutamine to keep systolic BP greater than 100 mm Hg. c) Administer metoprolol 5 mg IV push. d) Call for urine output less than 30 mL/h for 2 consecutive hours.
c) administer metoprolol 5 mg IV push. Explanation: Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a beta blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock.
A client is in the compensatory stage of shock. Which finding indicates the client is entering the progressive stage of shock? a) blood pressure of 110/70 mm Hg b) heart rate of 110 bpm c) urinary output of 20 ml per hour d) temperature of 99° F
c)urinary output of 20 ml per hour Explanation: In the compensatory stage of shock, the client exhibits moderate tachycardia, but as the shock continues to the progressive stage the client will have a decreased urinary output, hypotension, and mental confusion as a result of failure to perfuse and ineffective compensatory mechanisms. The body temperature initially may remain normal. These findings are indications that the body's compensatory mechanisms are failing.
Upon assessment of third-degree heart block on the monitor, what should the nurse do first? a) Call a code. b) Prepare for defibrillation. c) Begin cardiopulmonary resuscitation. d) Place transcutaneous pads on the client.
d) place transcutaneous pads on the client. Explanation: Transcutaneous pads should be placed on the client with third-degree heart block. For a client who is symptomatic, transcutaneous pacing is the treatment of choice. The hemodynamic stability and pulse should be assessed prior to calling a code or initiating CPR. Defibrillation is performed for ventricular fibrillation or ventricular tachycardia with no pulse.