NCLEX Review Q&A Medical Surgical

A client receiving an IV infusion of heparin sodium at 1,200 units / h. The dilution is 25,000 units / 500 mL. How many millileters per hour will this client receive?

· 500 mL / 25000 units * 1,200 units / 1 h = 24 mL/h

A 60-year old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is, acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4L/min, complete blood count (CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The nurse should first:

· Administering the morphine (The nurse's priority action should be relieving the crushing chest pain)

The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first:

· Assess for changes in vital signs (vital sign changes will reflect the severity of the sudden drop in cardiac output: decreased BP, increased HR, increase in respirations)

When a Client is experiencing a single PVC-on the Electrogram strip PVC's are characterized by a QRS of longer than 0.12 seconds and by a wide, notched, or slurred QRS complex. No P waves and the T wave is usually inverted. The nurse should:

· Assess the client for changes in the rhythm

A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?

· Blood pressure is 88/46 (Nitroglycerin is a vasodilator that will lower BP)

The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?

· Confusion, urine output 15 mL over the last 2 hours, orthopnea (Low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure)

When administering a thrombolytic drug to the client who is experiencing a myocardial infarction (MI) and who has premature ventricular contractions, the expected outcome of the drug is to:

· Dissolve clots (Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage)

A client is admitted with a myocardial infarction and arterial fibrillation. While auscultation the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as:

· Heart rate irregular with S3

A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following prescriptions from the health care provider should the nurse verify before implementing?

· Metoprolol (Lopressor) 5 mg IV push

An older adult had a myocardial infarction (MI) 4 days ago. At 9:30 am, the client's blood pressure is 102/64. After reviewing the client's progress notes (see chart), the nurse should first: Date: 1/10/14 Time: 12:30 am Urinary output for the last 4 hours: 90mL Capillary refill: >3 seconds Extremities: cool

· Notify the health care provider (all of the 12am assessments are signs of decreased cardiac output)

An older adult has chest pain and shortness of breath. The health care provider prescribed nitroglycerin tablets. What should the nurse instruct the client to do?

· Put the tablet under the tongue until it is absorbed

A client with chest pain rated 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What is the highest priority for nursing management of this client at this time?

· Reduce pain and myocardial oxygen demands · (Nursing management for a client with a myocardial infraction should focus on pain management and decreasing myocardial oxygen demand)

A client with acute chest pain is receiving IV morphine sulfate. Which of the following results are intended effects of morphine? Select all that apply

· Reduces myocardial oxygen consumption · Promotes reduction in respiratory rate · Reduces anxiety and fear (morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, BP, and HR)

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first:

· Take the client's blood pressure (The nurse should first address the client's tolerance to the drop in heart rate by checking the BP and level of consciousness and determine in Atropine is needed)