Cardiovascular Priority Questions
The wife of a client calls the clinic and tells the nurse her husband is having chest pain but won't go to the hospital. Which action should the nurse implement first? 1. Instruct the wife to call 911 immediately. 2. Tell the wife to have the client chew an aspirin. 3. Ask the wife what the client had to eat recently. 4. Request the husband talk to the clinic nurse.
2. Tell the wife to have the client chew an aspirin.
Ms. Teresa is completing discharge teaching for the client diagnosed with angina. Which statement indicates the client needs more teaching? "I must keep my nitroglycerin tablets in a dark bottle at all times." "I should walk at least 30 minutes at least three times a week." "I will decrease the number of cigarettes I smoke daily." "I am going to take one baby aspirin every day."
"I will decrease the number of cigarettes I smoke daily."
The charge nurse on a cardiac unit has received laboratory reports to assess. Which lab report is priority for the charge nurse to assess? 1. Ms. C.T., who is on a heparin drip. Allergies: NKDA Diagnosis: DVT Height: 66 inches Weight in pounds: 132 Weight in kg: 60 aPT 15 10—13 seconds INR 1.4 2.0—3.0 (therapeutic value) aPTT 56 25—35 seconds 2. Mr. R.S., who is scheduled for a coronary artery bypass graft (CABG) this morning. Allergies: Sulfa Diagnosis: CAD Height: 73inches Weight in pounds: 248 weight in kg: 112.73 INR 1.0 2.0—3 0 (therapeutic value) aPTT 34 25—35 seconds WBC 5.9 4.5-1. .0 (103 mm) RBC 4.9 4.7—5.1 (106 cells/mm) Hemoglobin 13.5 13.2-17.3 g/dL Hematocrit 44.2 Platelets 292 150-450 03 mm) 3. Ms. T.R., who had a cardiac cauterization 18 hours ago. Allergies: Penicillin Diagnosis: Chest pain Height: 62 inches Weight in pounds: 200 Weight in kg: 90.9 aPT 12 10—13 seconds INR 1.0 2.0-3.0 (therapeutic value) aPTT 29 25=35 seconds 4. Mr. J.E., who was admitted to rule out gallbladder disease. Allergies: NKDA Diagnosis: R/O Gallbladder Disease Height: 68 inches Weight in pounds: 198 Weight in kg: 90 aPT 9.8 10—13 seconds INR 1.3 2.0-3.0 (therapeutic value) aRTT 26 25—35 seconds Platelet 392 150-450 (103 mm)
#2, this client is scheduled for surgery this morning; therefore, the charge nurse must make sure that he is stale for the procedure and notify the surgeon if there is any reason to question the safety of the client having the procedure this morning
The nurse on the cardiac unit is discussing case management with a client who asks, "Why do I need a case manager for my heart disease?" Which statements are most appropriate for the nurse to respond? Select all that apply. 1. "Case management helps contain the costs of your healthcare." 2. "It will help enhance your quality of life with a chronic illness." 3. "It decreases the fragmentation of care across many healthcare settings." 4. "Case management is a form of health insurance for clients with chronic illnesses." 5. "We try to provide quality care along the healthcare continuum."
1,2,3,5
The cardiac nurse is teaching the client diagnosed with congestive heart failure. Which teaching interventions should the nurse discuss with the client? Select all that apply. 1. Notify the healthcare provider (HCP) if the client gains more than 2 1b in one day. 2. Keep the head of the bed elevated when sleeping. 3. Take the loop diuretic once a day before going to sleep. 4. Teach the client which foods are high in sodium and should be avoided. 5. Perform isotonic exercises at least once a day.
1,2,4,5
The nurse is initiating discharge teaching to a 68-year-old male client who had quadruple coronary bypass surgery. Which priority question should the nurse ask the client? 1. "Are you sexually active?" 2. "Can you still drive your car?" 3. "Do you have pain medications at home?" 4. "Do you know when to call your HCP?"
1. "Are you sexually active?"
The client on telemetry is showing ventricular tachycardia. Which action should the telemetry nurse delegate to the unlicensed assistive personnel (UAP)? 1. Have the UAP call the operator and announce the code. 2. Tell the UAP to answer the other call lights on the unit. 3. Send the UAP to the room to start rescue breaths. 4. Ask the family to step out of the room during the code.
2. Tell the UAP to answer the other call lights on the unit.
The nurse delegates post-mortem care to the unlicensed assistive personnel (UAP). The UAP tells the nurse she has never performed post-mortem care. Which statement is the best response by the nurse to the UAP? 1. "It can be uncomfortable. I will go with you and show you what to do." 2. "The client is already dead. You cannot hurt him now." 3. "There is nothing to it; it is just a bed bath and change of clothes." 4. "Don't worry. You can skip it this time but you need to learn what to do."
1. "It can be uncomfortable. I will go with you and show you what to do."
The client is diagnosed with end-stage congestive heart failure. The nurse finds the client lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement first? 1. Assist the client to a sitting position. 2. Assess the client's vital signs. 3. Call 911 for the paramedics. 4. Auscultate the client's lung sounds.
1. Assist the client to a sitting position.
The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and B/P increases to 210/130. Which intervention should the intensive care nurse implement first? 1. Discontinue the client's vasoconstrictor, dopamine. 2. Notify the healthcare provider. 3. Administer the vasopressor hydralazine. 4. Assess the client's neurological status.
1. Discontinue the client's vasoconstrictor, dopamine.
Which medication should the nurse administer first after receiving the morning shift report? 1. The IVPB antibiotic to the client with endocarditis admitted at 0530 today. 2. The antiplatelet medication to the client who had a myocardial infarction. 3. The coronary vasodilator patch to the client with coronary artery disease. 4. The statin medication to the client diagnosed with atherosclerosis.
1. The IVPB antibiotic to the client with endocarditis admitted at 0530 today.
The nurse is caring for clients on a cardiac unit. Which client should the nurse assess first? 1. The client diagnosed with angina who is reporting chest pain. 2. The client diagnosed with CHF who has bilateral 4+ peripheral edema. 3. The client diagnosed with endocarditis who has a temperature of 1000F. 4. The client diagnosed with aortic valve stenosis who has syncope.
1. The client diagnosed with angina who is reporting chest pain.
The male client presents to the emergency department with a complaint of chest $1 pain but does not have the ability to pay for the services. Which action should the emergency department nurse implement first? 1. Place the client on a telemetry monitor and assess the client. 2. Call an ambulance to transfer the client to a charity hospital. 3. Have the client sign a form agreeing to pay the bill. 4. Ask the client why he chose to come to this hospital.
1. Place the client on a telemetry monitor and assess the client.
The hospice nurse is working with a volunteer. Which task could the nurse delegate to the volunteer? 1. Sit with the client while he or she reminisces about life experiences. 2. Give the client a sponge bath and rub lotion on the bony prominences. 3. Provide spiritual support for the client and family members. 4. Check the home to see that all necessary medical equipment is available.
1. Sit with the client while he or she reminisces about life experiences.
The female family member of the client experiencing a cardiac arrest refuses to leave the client's room. Which intervention should the administrative supervisor implement? 1. Stay with the family member and explain what the team is doing. 2. Call hospital security to escort the family member out of the room. 3. Ask the healthcare provider (HCP) whether the family member can stay. 4. Ignore the family member unless she becomes hysterical.
1. Stay with the family member and explain what the team is doing.
The LPN informs the clinic nurse that the client diagnosed with atrial fibrillation has an INR of 4.5. Which intervention should the nurse implement? 1. Tell the LPN to notify the clinic healthcare provider (HCP). 2. Instruct the LPN to assess the client for abnormal bleeding. 3. Obtain a stat electrocardiogram on the client. 4. Take no action because this INR is within the normal range.
1. Tell the LPN to notify the clinic healthcare provider (HCP).
The nurse is administering medications to clients in the cardiac critical care area. Which client should the nurse question administering the medication? 1. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice. 2. The client receiving a beta-adrenergic blocker who has an apical heart rate of 62 beats/min. 3. The client receiving nonsteroidal anti-inflammatory drugs (NSAIDs) who has just finished eating breakfast. 4. The client receiving an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8.
1. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice.
The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first? 1. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints. 2. The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a I-to-IO pain scale. 3. The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally. 4. The client who has been turning on the call light frequently and stating her care has been neglected.
1. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints. RATIONALE: 1. This client may or may not be stable The client may have 'G no complaints" at this time, but the nurse must assess this client first to determine whatever the complaint was that brought the client to the ED has stabilized. This client should be seen first 2. It is important for the nurse to assess for pain relief in a timely manner, but this client has been medicated and the pain was a 3. The nurse can evaluate the amount of pain relief after making sure that the ED admission is stable. 3. This client has been back from the procedure and a bilateral pedal pulse indicates the client is stable; therefore, this client does need to be seen first. 4. Psychological issues are important, but not more so than a physiological issue, and the client admitted from the ED may have a physiological problem.
The charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse? 1. The client with acute rheumatic fever carditis who does not want to stay on bed rest. 2. The client who has the following ABG values: pH; 7.35; Pa02, 88; PaC02, 44; Hc03,22. 3. The client who is showing multifocal premature ventricular contractions (PVCs). 4. The client diagnosed with angina who is scheduled for a cardiac catheterization.
1. The client with acute rheumatic fever carditis who does not want to stay on bed rest.
The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first? 1. The client with coronary artery disease who is complaining that the nurses are being rude and won't answer the call lights. 2. The client diagnosed with an acute myocardial infarction w has an elevated creatinine phosphokinase-cardiac muscle (CPR-MB) level. 3. The client diagnosed with atrial fibrillation on an oral anticoagulant who has an International Normalized Ratio (INR) of 2.8. 4. The client 2 days' postoperative coronary artery bypass who is being transferred to the cardiac unit.
1. The client with coronary artery disease who is complaining that the nurses are being rude and won't answer the call lights.
The evening nurse in a long-term care facility is preparing to administer medications to a client diagnosed with atrial fibrillation. Which medication should the nurse question administering? Client: A Admit Number: 654321 Allergies: Penicillin Date: Today Height: 71 finches Weight: 77.27 kg/170 pounds Diagnosis: Atrial Fibrillation Medication 0701-1500 1501-2300 2301-0700 Warfarin (Coumadin) 5 mg PO daily 1800 INR: 3.4/t0day Metoclopramide (Reglan) 5 mg PO tid 0900 DN 1300 DN 1800 Docusate (Colace) PO bid 0900 DN 1800 Atorvastatin (Lipitor) PO daily 1. Warfarin (Coumadin), an anticoagulant. 2. Metoclopramide (Reglan), a gastric motility medication. 3. Docusate (Colace), a stool softener. 4. Atorvastatin (Lipitor), an antihyperlipidemic.
1. Warfarin (Coumadin), an anticoagulant
The home health (HH) aide tells the HH nurse that the grandson of the client she is caring for asked her out on a date. Which statement is the HH nurse's best response? 1. "1 am so excited for you; he seems like a very nice young man." 2. "You should not go out with him as long as she is a client of our agency." 3. "I think you should tell the director of the HH care agency about this date." 4. "You should never date someone you meet while taking care of a client."
2. "You should not go out with him as long as she is a client of our agency."
The registered nurse (RN) and licensed practical nurse (LPN) are caring for a group of clients on a cardiac unit. Which nursing task should not be assigned to the LPN? 1. Feed the client who has an IV in both forearms. 2. Assess the client diagnosed with stage IV heart failure. 3. Discharge the client who had a cardiac catheterization. 4. Administer the intravenous piggyback (IVPB) antibiotic ceftriaxone (Rocephin).
2. Assess the client diagnosed with stage IV heart failure.
The home health (HH) nurse is caring for an elderly client. Which nursing task should the nurse delegate to the HH aide? 1. Cook and freeze meals for the client. 2. Assist the client to sit on the front porch. 3. Take the client for outings to the store. 4. Monitor the client's mental status.
2. Assist the client to sit on the front porch.
The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement? 1. Call a Code Blue immediately. 2. Check the client's telemetry leads. 3. Find the nurse to check the client. 4. Remove the telemetry monitor.
2. Check the client's telemetry leads. RATIONALE: 1. The telemetry strip indicates an artifact, so there is no need for the UAP or any staff member to call a Code Blue, which is used when someone has arrested. 2. The UAP should be instructed to check the telemetry lead placement; this reading cannot be ventricular fibrillation because the client is talking to the nurse over the intercom system. This telemetry is an artifact; therefore, the leads should be checked and the UAP can do this because the client is stable. 3. The UAP can take care of this problem; there is no need for the primary nurse to check the client. 4. The strip indicates an artifact, but there is no indication that the client should be removed from telemetry.
The UAP working in a long-term care facility notifies the nurse that the client diagnosed with congestive heart failure who is on a low-sodium diet is complaining that the food is inedible. Which intervention should the nurse implement first? 1. Have the family bring food from home for the client. 2. Check to see what the client has eaten in the past 24 hours. 3. Tell the client that a low-sodium diet is an important part of the diagnosis. 4. Ask the dietician to discuss food preferences with the client.
2. Check to see what the client has eaten in the past 24 hours.
The nurse is administering medications on a cardiac unit. Which medication should the nurse question administering? 1. Warfarin (Coumadin), an anticoagulant, to a client with a prothrombin time (PT) of 14 and an International Normalized Ratio (INR) of 1.6 mg/dL. 2. Digoxin (Lanoxin), a cardiac glycoside, to a client with a potassium level of 3.3 mEq/L. 3. Atenolol (Tenormin), a beta-blocker, for the client with an aspirate aminotransferase (AST) of 18 U/L. 4. Lisinopril (Zestril), an ACE-inhibitor, for the client with a serum creatinine level of 0.8 mg/dL.
2. Digoxin (Lanoxin), a cardiac glycoside, to a client with a potassium level of 3.3 mEq/L.
The elderly client on the cardiac unit was found on the floor b) the bed. Which information should the nurse document in the client's chart? 1. Fell. No injuries noted. Incident report completed. HCP notified. 2. Found on floor. No complaints of pain. Able to move all extremities. 3. States no one answered call light, so attempted to get up without help. 4. Got out of bed without assistance and fell by the bedside.
2. Found on floor. No complaints of pain. Able to move all extremities.
The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager? 1. Discuss personal information the client shared with the nurse in confidence. 2. Provide the case manager with any information that is required for continuity of care 3. Explain that client confidentiality prevents the nurse from disclosing information. 4. Ask the case manager to get the client's permission before sharing information.
2. Provide the case manager with any information that is required for continuity of care RATIONALE: 1. Unless the information shared is directly connected to healthcare issues, the nurse should not share confidential information with anyone else. The nurse should inform clients that information directly affecting the client's healthcare will be shared on a need-to-know basis only. 2. The case manager's job is to ensure continuity and adequacy of care for the client. This individual has a "need to know." 3. The case manager is part of the healthcare team; therefore, information should be shared. 4. The client gave permission when being admitted to the hospital for information to be shared among those providing care. The case manager does not need to obtain further consent.
The home health (HH) nurse is visiting a client diagnosed with congestive heart failure. The client has an out-of-hospital do not resuscitate (DNR) order, has stopped breathing, and has no pulse or blood pressure. The client's family is at the bedside. Which intervention should the HH nurse implement first? 1. Contact the agency's chaplain. 2. Pronounce the client's death. 3. Ask the family to leave the bedside. 4. Call the client's funeral home.
2. Pronounce the client's death.
The charge nurse on the cardiac unit is counseling a female staff nurse because the nurse has clocked in late multiple times for the 7:00 a.m. to 7:00 p.m. shift. Which conflict resolution uses the win-win strategy? 1. The charge nurse terminates the staff nurse as per the hospital policy so that a new nurse can be transferred to the unit. 2. The charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 a.m. to 9:00 p.m. shift. 3. The charge nurse puts the staff nurse on probation with the understanding that the next time the staff nurse is late to work she will be terminated. 4. The staff nurse asks another staff member to talk to the charge nurse to explain that she is a valuable part of the team.
2. The charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 a.m. to 9:00 p.m. shift.
Which client should the cardiac nurse assess first after receiving the p.m. shift report? I. The client who is completing the second unit of PRBCs. 2. The client who is crying after being informed of a terminal diagnosis. 3. The client who refused to eat the dietary tray but got food from home. 4. The client who became short of breath ambulating in the hallway.
2. The client who is crying after being informed of a terminal diagnosis.
The surgical nurse is admitting a client having heart surgery to the operating room. Which information would require the nurse to call a time-out? 1. The client is drowsy from the preoperative medication and drifts off to sleep. 2. The consent form states mitral valve replacement and the client states aortic valve replacement. 3. The chart and client's armband states the client is allergic to the narcotic analgesic morphine. 4. The client states his or her name and birth date as it appears on the chart.
2. The consent form states mitral valve replacement and the client states aortic valve replacement.
The charge nurse on the cardiac unit has to float a nurse to the emergency department for the shift. Which nurse should be floated to the emergency department? 1. The nurse who has 4 years of experience on the cardiac unit. 2. The nurse who just transferred from critical care to the cardiac unit. 3. The nurse with 1 year of experience on the cardiac unit who has been on a week's sick leave. 4. The nurse who has worked in the operating room for 2 years and in the cardiac unit for 3 years.
2. The nurse who just transferred from critical care to the cardiac unit. RATIONALE: 1. The nurse who just has surgical nursing experience would not be the choice to float to the emergency department. 2. The nurse with critical care experience would be the best choice to float to the emergency department 3. The nurse just returning from sick leave would not be a good choice to send to the emergency department, which may be very busy at times. 4. This nurse has not had experience in critical care; therefore, this nurse would not be the best choice to float to the emergency department.
The nurse received an aPTT report on a client receiving heparin via continuous drip infusion. According to the report, the client's drip rate should be decreased by 100 units per hour. The heparin comes prepared as 25 ,000 units in 500 mL of fluid. The current rate of infusion is 26 mL per hour. At what rate should the nurse set the pump?
24 mL per hour 25,000 divided by 500 mL= 50 units of heparin per mL 26 (current rate) x 50=1300 units of heparin currently infusing 1300-100=1200 units of heparin needed as new infusion rate 1200/50=24 mL per hour to infuse
The cardiac clinic nurse hears the UAP tell the client, "You have gained over 15 pounds since your last visit." The scale is located in the office area. Which action should the clinic nurse implement? 1. Tell the UAP in front of the client to not comment on the weight. 2. Ask the UAP to put the client in the room and take no action. 3. Explain to the UAP, in private, that this is an inappropriate comment and violates HIPAA. 4. Report the UAP to the director of nurses of the clinic.
3. Explain to the UAP, in private, that this is an inappropriate comment and violates HIPAA.
The nurse is preparing to administer digoxin 0.25 mg IVP to a client in severe congestive heart failure who is receiving D5W/0.9 NaCL at 25 mL/hr. Rank in order of importance. 1. Administer the medication over 5 minutes. 2. Dilute the medication with normal saline. 3. Draw up the medication in a tuberculin syringe. 4. Check the client's identification band. 5. Clamp the primary tubing distal to the port.
3,2,4,5,1
The hospice nurse is discussing the clients' care with the unlicensed assistive personnel (UAP), Which statement contains the best information about caring for a client with end-stage heart failure who is dying? 1. "Perform as much care for the client as possible to conserve his or her strength." 2. "Do not get too attached to the client because it will hurt when he or she dies." 3. "Be careful not to promise to withhold healthcare information from the team." 4. "The client may want to talk about his or her life, but you should discourage that.
3. "Be careful not to promise to withhold healthcare information from the team."
The client in room 420 is complaining of severe chest pain of 10 on a I-to-IO pain scale. Which intervention should the nurse implement first? 1. Check the client's MAR for the last time medication was administered. 2. Assess the client's apical pulse, blood pressure, and lung sounds. 3. Administer a sublingual nitroglycerin to the client. 4. Place oxygen via nasal cannula at 6 L/min.
3. Administer a sublingual nitroglycerin to the client.
The client on the cardiac unit has a cardiac arrest. Which is the administrative supervisor nurse's first intervention during the code? 1. Begin to take notes to document the code. 2. Make sure all the jobs are being done. 3. Arrange for an intensive care unit bed. 4. Administer the emergency medications.
3. Arrange for an intensive care unit bed.
The nurse is providing end-of-life care to the client diagnosed with cardiomyopathy who is in hospice. Which priority assessment intervention should the nurse implement? 1. Assess the client's spiritual needs. 2. Assess the client's financial situation. 3. Assess the client's support system. 4. Assess the client's medical diagnosis.
3. Assess the client's support system.
The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse? 1. Assign an RN to perform all sterile procedures. 2. Assign an LPN to give all IV medications. 3. Assign an UAP to complete the a.m. care. 4. Assign an LPN to write the care plans.
3. Assign an UAP to complete the a.m. care. RATIONALE: 1. An LPN can perform sterile procedures such as inserting indwelling catheters and IV catheters. An RN should perform the functions that require nursing judgment, such as planning and evaluating the care of the clients. 2. Although an LPN could administer most intravenous piggyback (IVPB) medications, only qualified RNs may administer intravenous push (IVP) medications and chemotherapy. 3. A UAP is capable of performing the morning care. This is an appropriate nursing task to delegate, 4. Writing a care plan for a client requires nursing judgment; therefore, an RN should be assigned this function.
The intensive care unit nurse and a UAP are caring for a client who has had a coronary artery bypass graft (CABG). Which nursing task should the nurse assign to the UAP? 1. Monitor the client's arterial blood gases. 2. Re-infuse the client's blood using the cell saver. 3. Assist the client to take a sponge bath. 4. Change the client's saturated leg dressing.
3. Assist the client to take a sponge bath.
The cardiac clinic nurse has told the female unlicensed assistive personnel (UAP) twice to change the sharps container in the examination room, but it has not been changed. Which action should the nurse implement first? 1. Tell the UAP to change it immediately. 2. Ask the UAP why the sharps container has not been changed. 3. Change the sharps container as per clinic policy. 4. Document the situation and place a copy of the documentation in the employee file.
3. Change the sharps container as per clinic policy.
The unlicensed assistive personnel (UAP) tells the nurse the client is complaining of chest pain. Which task should the nurse delegate to the UAP? 1. Call the healthcare provider (HCP) and report the client's chest pain. 2. Give a client some acetaminophen (Tylenol) while the nurse checks the client. 3. Get the client's medical records and bring them to the client's room. 4. Notify the client's family of the onset of chest pain.
3. Get the client's medical records and bring them to the client's room.
The nurse and the UAP enter the client's room and discover that the client is unresponsive. Which action, according to the American Heart Association (AHA) guidelines, should the nurse assign to the UAP first? 1. Ask the UAP to check whether the client is asleep. 2. Tell the UAP to perform cardiac compressions. 3. Instruct the UAP to get the crash cart. 4. Request the UAP to put the client in a recumbent position.
3. Instruct the UAP to get the crash cart.
The nurse in a critical care cardiac unit is administering medications to a client. Which intervention should the nurse implement first? 1. Check the radial pulse before administering digoxin, a cardiac glycoside. 2. Monitor the amiodarone level for the client receiving amiodarone. 3. Obtain the latest PTT results on the client with a heparin drip. 4. Check the liver function panel for the client receiving a dopamine drip.
3. Obtain the latest PTT results on the client with a heparin drip.
The client admitted to rule out (R/O) a myocardial infarction is complaining of substernal chest pain radiating to the left arm and jaw. Which intervention should the nurse implement first? 1. Take the clients pulse, respirations, and blood pressure 2. Call for a stat electrocardiogram and a troponin level 3. Place sublingual nitroglycerin 1/150 g under the tongue 4. Notify the HCP that the client has pain
3. Place sublingual nitroglycerin 1/150 g under the tongue
The home health (HH) nurse is completing the admission assessment for an obese client diagnosed with a myocardial infarction with comorbid type 1 diabetes and arterial hypertension. Which priority intervention should the nurse implement? 1. Encourage the client to walk 30 minutes a day. 2. Request an HH-registered dietician to talk to the client. 3. Refer the client to a cardiac rehabilitation unit. 4. Discuss the client's need to lose 1 to 2 pounds a week.
3. Refer the client to a cardiac rehabilitation unit.
The elderly client on a cardiac unit has a do not resuscitate (DNR) order written. Which intervention should the nurse implement? 1. Continue to care for the client's needs as usual. 2. Place notification of the DNR inside the client's chart. 3. Refer the client to a hospice organization. 4. Limit visitors to two at a time, so as not to tire the client.
3. Refer the client to a hospice organization.
The nurse is preparing to administer two units of PRBCs to a client diagnosed with congestive heart failure (CHF). Which HCP order should the nurse question? 1. Administer each unit over 2 hours. 2. Administer the loop diuretic furosemide (Lasix) IVP once. 3. Restrict the client's fluids to 1000 mL per 24 hours. 4. Have a complete blood count (CBC) done the following morning.
3. Restrict the client's fluids to 1000 mL per 24 hours.
The home health (HH) nurse is preparing for the initial visit to a client diagnosed with congestive heart failure. Which intervention should the HH nurse implement first? 1. Prepare all the needed equipment for the visit. 2. Call the client to arrange a time for the visit. 3. Review the client's referral form/pertinent data. 4. Make the necessary referrals for the client.
3. Review the client's referral form/pertinent data.
The husband of the client diagnosed with infective endocarditis and who has a do not resuscitate (DNR) tells the nurse, "My wife is not breathing." Which intervention should the nurse implement first? 1. Contact the clients healthcare provider (HCP). 2. Notify the Rapid Response Team. 3. Stay with the client and her husband. 4. Instruct the CAP to perform post-mortem care.
3. Stay with the client and her husband.
The nurse at a disaster site is triaging victims when a woman states, "I am a certified nurse aide. Can I do anything to help?" Which action should the nurse implement? 1. Request the woman to please leave the area. 2. Ask the woman to check the injured clients. 3. Tell the woman to try and keep the victims calm. 4. Instruct the woman to help the paramedics.
3. Tell the woman to try and keep the victims calm.
The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65 -year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.
3. The 75-year-old client scheduled for a cardiac catheterization. RATIONALE: 1. This client is at high risk for complications related to necrotic myocardial tissue and will need extensive teaching; therefore, this client should not be assigned to a new graduate. 2. Unstable angina means this client is at risk for life-threatening complications and should not be assigned to a new graduate. 3. A new graduate should be able to complete $3 a pre-procedural checklist and get this client to the catheterization lab. 4. Chest pain means this client could be having a myocardial infarction and should not be assigned to a new graduate.
The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first? 1. The cardiac glycoside to the client who has an apical pulse of 58. 2. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L, 3. The antidysrhythmic to the client in ventricular fibrillation. 4. The calcium-channel blocker who has a blood pressure of 110/68.
3. The antidysrhythmic to the client in ventricular fibrillation. RATIONALE: 1. The cardiac glycoside, such as digoxin, should not be administered unless the apical pulse is 60 or above. 2. Because the client's serum level is already low, the nurse should question administering a loop diuretic. 3. The client in ventricular fibrillation is in a situation; therefore, the antidysrhythmic, such as lidocaine or amiodorone, should be administered first 4. The client's blood pressure is above 90/60, so the calcium-channel blocker can be administered but it is not priority over a client who is in a life-threatening situation.
The nurse is administering medications to clients on a cardiac unit. Which medication should the nurse question administering? 1. The loop-diuretic furosemide (Lasix) to a client who had a 320-mL output in 4 hours. 2.The anticoagulant enoxaparin (Lovenox) to a client who had open-heart surgery. 3. The antiplatelet ticlopidine (Ticlid) to a client being prepared for surgery. 4. The ACE inhibitor captopril (Capoten) to a client who has a B/P of 100/68.
3. The antiplatelet ticlopidine (Ticlid) to a client being prepared for surgery.
The charge nurse on the cardiac unit is making shift assignments. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with mitral valve stenosis. 2. The client diagnosed with asymptomatic sinus bradycardia. 3. The client diagnosed with fulminant pulmonary edema. 4. The client diagnosed with acute atrial fibrillation.
3. The client diagnosed with fulminant pulmonary edema.
The cardiac nurse received laboratory results on the following clients. Which client warrants immediate intervention from the nurse? 1. The client who has an INR of 2.8. 2. The client who has a serum potassium level of 3.8 mEq/L. 3. The client who has a serum digoxin level of 2.6 mg/dL. 4. The client who has a glycosylated hemoglobin of 6%.
3. The client who has a serum digoxin level of 2.6 mg/dL.
The hospice nurse is triaging phone calls from clients. Which client should the nurse call first? 1. The client whose family reports the client is not eating. 2. The client who wants to rescind the out-of-hospital DNR. 3. The client whose pain is not being controlled with the current medications. 4. The client whose urinary incontinence has caused a Stage 1 pressure ulcer.
3. The client whose pain is not being controlled with the current medications.
The director of nurses in the cardiac clinic is counseling an unlicensed assistive personnel (UAP) in the clinic who returned late from her lunch break seven times in the past 2 weeks. Which conflict resolution uses the win-lose strategy? 1. The UAP explains she is checking on her ill mother during lunch, and the nurse allows her to take a longer lunch break if she comes in early. 2. The director of nurses offers the UAP a transfer to the emergency weekend clinic so that she will be off during the week. 3. The director (f nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly. 4. The UAP is p] aced on I-month probation, and any further occurrences will result in termination from this position.
3. The director (f nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly.
The client diagnosed with arterial hypertension and has been taking a calcium channel blocker, a loop diuretic, and an ACE inhibitor for 3 years. Which statement by the client would warrant intervention by the nurse? 1. "I have to go to the bathroom a lot during the morning." 2. "I get up very slowly when I have been sitting for a while." 3. "I do not salt any food when I am cooking it but I add it at the table." 4. "I drink grape fruit juice every morning with my breakfast."
4. "I drink grape fruit juice every morning with my breakfast."
Which information should the experienced home health (HH) nurse discuss when orienting a new nurse to HH nursing? 1. If the client or family is hostile or obnoxious, call the police. 2. Carry the HH care agency identification in a purse or wallet. 3. Visits can be scheduled at night with permission from the agency. 4. Inform the agency of the times of the client's scheduled visits.
4. Inform the agency of the times of the client's scheduled visits.
The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which delegation task warrants intervention by the charge nurse of the cardiac unit? 1. The UAP is instructed to bathe the client who is on telemetry. 2. The UAP is requested to obtain a bedside glucometer reading. 3. The UAP is asked to assist with a portable chest x-ray. 4. The UAP is told to feed a client who is dysphagic.
4. The UAP is told to feed a client who is dysphagic.
Which client warrants immediate intervention by the nurse? 1. The client diagnosed with pericarditis who has chest pain with inspiration. 2. The client diagnosed with mitral valve regurgitation who has thready peripheral pulse. 3. The client diagnosed with Marfan syndrome who has pectus excavatum. 4. The client diagnosed with atherosclerosis who has slurred speech and drooling.
4. The client diagnosed with atherosclerosis who has slurred speech and drooling.
The home health (HH) nurse received phone messages from the agency secretary. Which client should the nurse phone first? 1. The client diagnosed with hypertension who is reporting a BP of 148/92. 2. The client diagnosed with cardiomyopathy who has a pulse oximeter reading of 93 %. 3. The client diagnosed with congestive heart failure who has edematous feet. 4. The client diagnosed with chronic atrial fibrillation who is having chest pain.
4. The client diagnosed with chronic atrial fibrillation who is having chest pain.
Which client should the telemetry nurse assess first after receiving the a.m. shift report? 1. The client diagnosed with deep vein thrombosis who has an edematous right calf. 2. The client diagnosed with mitral valve stenosis who has heart palpitations. 3. The client diagnosed with arterial occlusive disease who has intermittent claudication. 4. The client diagnosed with congestive heart failure who has pink frothy sputum.
4. The client diagnosed with congestive heart failure who has pink frothy sputum. RATIONALE: 1. The nurse would expect the client with a deep vein thrombosis to have an edematous right calf, so the nurse would not need to assess this client first. 2. The nurse would expect the client with mitral valve stenosis to have heart palpitations (sensations of rapid, fluttering heartbeat). 3. The nurse would expect the client with arterial occlusive disease to have intermittent claudication (leg pain), so the nurse would not need to assess this client first. 4.The client would not: expect the client with congestive heart failure to have pink, frothy sputum because this is a sign of pulmonary edema. his client should be assessed first.
The cardiac nurse is preparing to administer one unit of blood to a client. Which interventions should the nurse implement? Rank in order of priority. 1. Infuse the unit of blood at 20 gtts/min the first 15 minutes. 2. Check the unit of blood and the client's blood band with another nurse. 3. Initiate Y-tubing with normal saline via an 18-gauge angio catheter. 4. Assess the client's vital signs and lung sounds, and assess for a rash. 5. Obtain informed consent for the unit of blood from the client.
5,4,3,2,1
The client is in ventricular tachycardia. Which intervention should the nurse implement first? Defibrillate the client. Assess the carotid pulse. Administer epinephrine IVP. Start cardiopulmonary resuscitation.
Assess the carotid pulse.
The telemetry technician tells the primary nurse the client in room 420 has a straight line. Which intervention should the primary nurse implement first? Instruct the UAP to take the crash cart to room 420. Tell the telemetry technician to call the Rapid Response Team. Determine if the client has an apical pulse and blood pressure. Check to see if the client has the telemetry leads on the chest.
Check to see if the client has the telemetry leads on the chest.
Which nursing task is most appropriate for Ms. Teresa to delegate to the UAP? Request the UAP to obtain the newly admitted client's weight. Ask the UAP to clean the room for the client who has been discharged. Tell the UAP to take the vital signs on the client who is hypovolemic. Instruct the UAP to discuss the low-fat, low-cholesterol diet with the client.
Request the UAP to obtain the newly admitted client's weight.
Ms. Teresa is transcribing the healthcare provider's admissions orders for a client being admitted for R/O myocardial infarction. Which ACP's order should Ms. Teresa question? Draw cardiac isoenzymes every 6 hours. Provide low-fat, low-cholesterol diet. Administer morphine IVI) 2 mg every 5 minutes for chest pain. Schedule client for endoscopy in a.m.
Schedule client for endoscopy in a.m.
The primary nurse has instructed the unlicensed assistive personnel (UAP) to assist the client in 410 to the bathroom for a shower. Which action by the UAP warrants intervention by the primary nurse? The UAP did not notify the desk the telemetry was being removed. The UAP did not remove the electrodes from the client's chest. The UAP placed a bath chair in the shower for the client. The UAP stayed in the client's bathroom while the client showered.
The UAP did not notify the desk the telemetry was being removed.
Which client should Ms. Teresa assign to the most experienced RN on the unit? The client diagnosed with atrial fibrillation who is receiving the first dose of praxada (dabigatran). The client diagnosed with congestive heart failure who is coughing up pink, frothy sputum. The client diagnosed with a myocardial infarction who is exhibiting occasional premature ventricular contractions. The client diagnosed with mitral valve prolapse who is complaining of shortness of breath when sitting in the chair.
The client diagnosed with congestive heart failure who is coughing up pink, frothy sputum.
Ms. Teresa is looking over the morning laboratory results. Which client warrants Ms. Teresa notifying the healthcare provider (HCP)? The client receiving IMP digoxin who has a digoxin level of 2.4 mg/dL. The client receiving Coumadin (warfarin) who has an INR of 1.2. The client receiving furosemide who has a potassium level of 3.5 mEq/L. The client receiving nystatin who has a cholesterol level of 205.
The client receiving IMP digoxin who has a digoxin level of 2.4 mg/dL.
Which client should Ms. Teresa assign to the LPN? The client who was just admitted from the emergency department to the unit. The client who is exhibiting supraventricular tachycardia on the telemetry. The client who had a left femoral cardiac catheterization this morning. The client who needs teaching concerning coronary artery disease.
The client who had a left femoral cardiac catheterization this morning.
