ATI Perfusion

A nurse is caring for a client following a myocardial infarction. The client tells the nurse that she doubts her ability to maintain a low-cholesterol diet. Which of the following responses should the nurse make? A. What about the low-cholesterol diet concerns you? B. If you don't follow the diet, you will probably have another heart attack. C. I've been on this diet for the last 5 years. You will learn to change your eating habits after a while. D. I will have a dietician talk to you to provide some guidance

A. what about the low-cholesterol diet concerns you?

A nurse is completing an assessment on a client. Which of the following findings should the nurse identify as a risk factor for coronary heart disease? (Select all that apply) A. hypothyroidism B, hypertension C. Diabetes mellitus D. hyperlipidemia E. tobacco smoking

B,C,D,E

A nurse is in the emergency department when several hundred clients who were injured in a train collision arrive at the facility for treatment. Which of the following clients requires immediate treatment? A. a client who has neck pain and transported to the facility on a backboard. B. A client who had epigastric pain and left arm pain and is diaphoretic C. A client who has nasal and orbital ecchymosis and a respiratory rate of 16/min D. A client who has abdominal pain and is 2 months pregnant.

B. A client who has epigastric pain and left arm pain and is diaphoretic

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of skin integrity? A. 3+ Achilles reflex B. Faint pedal pulses C. Feet warm to touch bilaterally D. Capillary refill of <2 sec

B. Faint pedal pulses

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states that, "All this equipment is making me nervous." Which of the following responses should the nurse offer? A. you won't need the equipment for very long B. all of this equipment can be frightening C. why does the equipment bother you? D. let me tell you about what each machine does?

B. all of this equipment can be frightening

A nurse is caring for a client who has difficulty breathing. The nurse should assist the client into which of the following positions? A. Supine B. Lateral C. Fowler's D. Trendelenburg

C. Fowler's

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines C. Palpate for respiratory excursion D. Perform a blanch test

D. Perform a blanch test The blanch test is used to check for capillary refill which is an indicator for peripheral circulation and tissue perfusion

A nurse is planning for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care? A. instruct the client about a long-term cardiac conditioning program B. administer schedules doses of acetaminophen C. check for peak laboratory markers of myocardial damage D. monitor for bleeding

D. monitor for bleeding

A nurse in an emergency department is caring for a client who is having an acute myocardial infraction. The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety? A. nitrogylcerin B. aspirin C. oxygen D. morphine

D. morphine

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction (MI). Which of the following manifestations should the nurse identify as indications of MI? (Select all that apply?) A. nausea and vomiting B. diaphoresis and dizziness C. chest and left arm pain that subsides with rest D. anxiety and feelings of doom E. bounding pulse and bradypnea

A. nausea and vomiting B. diaphoresis and dizziness D. anxiety and feelings of doom

A nurse is examining the ECG of a client who is having an acute myocardial infarction. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations? A. necrosis B. hypokalemia C. hypomagnesemia D. insufficiency

A. necrosis

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? A. cardiogenic shock B. dysrhythmias C. heart failure D. Pulmonary edema

B. dysrhythmias

A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make? A. "Take only one dose of nitroglycerin to reduce the risk of getting a headache." B. "There's nothing that can be done to relieve the headaches that nitroglycerin causes." C. "Try taking a mild analgesic to relieve the headache." D. "We will ask the provider to prescribe a different medication for you."

C. "Try taking a mild analgesic to relieve the headache."

A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious sounds should the nurse document? A. coarse crackles B. wheezes C. rhonchi D. friction rub

A. coarse crackles

A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? A. elevated ST segments B. absent P waves C. depressed ST segments D. varying PP intervals

A. elevated ST segments

A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When assessing the client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors? A. peripheral vascular resistance increases B. The sensitivity of blood pressure-adjusting baroreceptors increases. C. blood is hypercoagulable and clots more quickly. C. Cardiac medications are less effective.

A. peripheral vascular resistance increases

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? A. these tests help determine the degree of damage to the heart tissues B. cardiac enzymes will identify the location of the MI C. these tests will enable the provider to determine the heart structure and mobility of the heart valves D. cardiac enzymes assist in diagnosing the presence of pulmonary congestion

A. these tests help determine the degree of damage to the heart tissues

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? A. "A headache is an indication of an allergy to the medication. B. ""A headache is an expected adverse effect of the medication." C. "A headache indicates tolerance to the medication." D. "A headache is likely due to the anxiety about the chest pain."

B. ""A headache is an expected adverse effect of the medication."

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using the Doppler ultrasound stethoscope B. Count the client's pedal pulses C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 sec

C. Count the apical pulse for 1 full min and describe the rhythm in the chart

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? A. check the client's blood pressure B. auscultate heart tones C. Perform 12-lead ECG D. determine if the pain radiates to the left arm

C. Perform 12-lead ECG

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal B. Troponin is a lipid whose levels reflect the risk for coronary artery disease C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. D. Troponin is a protein that helps transport oxygen throughout the body.

C. Troponin is a heart muscle protein that appears in the bloodstream

A nurse is monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hours? A. Infective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli

C. Ventricular dysrhythmias

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? A. sudden hemoptysis B. acute diarrhea C. frontal headache D. acute confusion

C. acute confusion

A client who has a history of MI is prescribed aspirin (325mg). The nurse recognizes that the aspirin is given due to which of the following actions of the medications. A. analgesic B. anti-inflammatory C. antiplatelet aggregate D. antipyretic

C. antiplatelet aggregate

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? A. attach the leads for a 12-lead ECG B. obtain a blood sample C. initiate oxygen therapy D. insert the IV catheter

C. initiate oxygen therapy

A nurse is caring for a client who is having a possible myocardial infarction (MI). Which of the following findings should the nurse identify as an associated manifestation of an MI? A. headache B. hemoptysis C. nausea D. diarrhea

C. nausea

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply.) A. orthopnea B. headache C. nausea D. tachycardia E. diaphoresis

C. nausea D. tachycardia E. diaphoresis

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? A. increased BP and decreases pulse rate B. jugular vein distention and peripheral edema C. report of sudden, sever back pain D. report of retrosternal chest pain radiating to the left arm

C. report of sudden, severe back pain

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). Which is the most common assessment finding with acute MI? A. dyspnea B. pain in the shoulder and left arm C. substernal chest pain D. palpitations

C. substernal chest pain

A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated? A. aspartate aminotransferase (AST) B. unconjugated bilirubin C. troponin I D. serum amylase

C. troponin I

While participating in a community health fair, a client who has a blood pressure of 150/90 mmHg during screening. Which of the following actions should the nurse take? A. give the client a written record of his BP to bring to his provider B. encourage the client to go to the nearest emergency department C. instruct the client to follow-up with a provider within 6 months D. Explain to the client that he is not at risk unless he has manifestations of hypertension.

a. Give the client a written record of his BP to bring to his provider