Chapter 38:
The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below:After calling for assistance and a defibrillator, which action should the nurse take next? a.Perform a pericardial thump. b.Initiate cardiopulmonary resuscitation (CPR). c.Start an 18-gauge intravenous line. d.Ask the client's family about code status.
ANS: b
A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a.Assess the IV site hourly. b.Monitor the pedal pulses. c.Monitor the client's vital signs. d.Obtain consent for a central line.
ANS:A Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the client's integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working.DIF:Applying/ApplicationREF:773KEY:Inotropic agents| adverse effects| medication safetyMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a.Allow family members to remain at the bedside. b.Ask the family if the client would like a fan in the room. c.Keep the television tuned to the client's favorite channel. d.Speak loudly to the client in case of hearing problems.
ANS:AAllowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs throughair movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.DIF:Applying/ApplicationREF:780KEY:Intra-aortic balloon pump| nonpharmacologic comfort measuresMSC:Integrated Process: Nursing Process: Implementation NOT:Client Needs Category: Physiological Integrity: Basic Care and Comfort
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?a.Mid-sternal chest pain b.Increased urine output c.Mild orthostatic hypotension d.P wave touching the T wave
ANS:AChest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output andmild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.DIF:Applying/ApplicationREF:663KEY:Cardiac electrical conductionMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care
A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a."Continue to educate the client on possible healthy changes." b."Emphasize complications that can occur with noncompliance." c."Tell the client that denial is normal and will soon go away." d."You need to make sure the client understands this illness."
ANS:AClients are often in denial after a coronary event. The client who seems to be in denial but iscompliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client toverbalize understanding of the illness is also potentially threatening to the client.DIF:Understanding/ComprehensionREF:769KEY:Coronary artery disease| psychosocial response| coping| therapeutic communicationMSC:Integrated Process: Communication and DocumentationNOT:Client Needs Category: Psychosocial Integrity
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a.Assess for any hemodynamic effects of the rhythm. b.Prepare to administer antidysrhythmic medication. c.Notify the provider or call the Rapid Response Team. d.Turn the alarms off on the cardiac monitor.
ANS:AOlder clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.DIF:Applying/ApplicationREF:769KEY:Coronary artery disease| older adult| pathophysiology| nursing assessmentMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Health Promotion and Maintenance
A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching? a."Minimize or abstain from caffeine." b."Lie on your side until the attack subsides." c."Use your oxygen when you experience PACs." d."Take amiodarone (Cordarone) daily to prevent PACs."
ANS:APACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.DIF:Applying/ApplicationREF:663KEY:Patient education| cardiac electrical conductionMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Health Promotion and Maintenance
13.A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home healthnurse upon discharge? a.Medication reconciliation b.Immunization history c.Religious beliefs d.Nutrition preferences
ANS:AThe home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.DIF:Applying/ApplicationREF:673KEY:Hand-off communicationMSC:Integrated Process: Communication and DocumentationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care
A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a.A 45-year-old who takes an aspirin daily b.A 50-year-old who is post coronary artery bypass graft surgery c.A 78-year-old who had a carotid endarterectomy d.An 80-year-old with chronic obstructive pulmonary disease
ANS:B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.DIF:Applying/ApplicationREF:666KEY:Health screening| cardiac electrical conductionMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care
An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram?(Select all that apply.) a.Hypertension b.Fatigue despite adequate rest c.Indigestion d.Abdominal pain e.Shortness of breath
ANS:B, C, EWomen may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.DIF:Applying/ApplicationREF:635KEY:Cardiac electrical conductionMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Physiological Adaptation
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best?a."The t-PA didn't dissolve the entire coronary clot." b."The heparin keeps that artery from getting blocked again." c."Heparin keeps the blood as thin as possible for a longer time." d."The heparin prevents a stroke from occurring as the t-PA wears off."
ANS:BAfter the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such.DIF:Understanding/ComprehensionREF:768KEY:Coronary artery disease| thrombolytic agents| patient educationMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medicationshould the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a.Sotalol (Betapace) b.Warfarin (Coumadin) c.Atropine (Sal-Tropine) d.Lidocaine (Xylocaine)
ANS:BAtrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.DIF:Applying/ApplicationREF:667KEY:Cardiac electrical conduction| medicationMSC:Integrated Process: Nursing Process: AnalysisNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing ofthe heart rate? a."Make certain that your bath water is warm." b."Avoid straining while having a bowel movement." c."Limit your intake of caffeinated drinks to one a day." d."Avoid strenuous exercise such as running."
ANS:BBearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.DIF:Applying/ApplicationREF:663KEY:Functional abilityMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Physiological Integrity: Basic Care and Comfort
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a.Sinus tachycardia b.Speech alterations c.Fatigue d.Dyspnea with activity
ANS:BClients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.DIF:Applying/ApplicationREF:666KEY:Cardiac electrical conduction| vascular perfusionMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causesthe nurse to consider additional referrals? a.Dirty carpets in need of vacuuming b.Expired food in the refrigerator c.Old medications in the kitchen d.Several cats present in the home
ANS:BExpired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern.DIF:Applying/ApplicationREF:781KEY:Home safety| referrals| coronary artery bypass graftMSC:Integrated Process: Communication and DocumentationNOT:Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Whichaction should the nurse take prior to the initiation of cardioversion?a.Administer intravenous adenosine. b.Turn off oxygen therapy. c.Ensure a tongue blade is available. d.Position the client on the left side.
ANS:BFor safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.DIF:Remembering/KnowledgeREF:668KEY:Assessment/diagnostic examination| safetyMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a.Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b.Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c.Client who is 1 day post percutaneous coronary intervention, going home this morning d.Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking
ANS:BHypertension after coronary artery bypass graft surgery can be dangerous because it puts toomuch pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.DIF:Analyzing/AnalysisREF:777KEY:Coronary artery disease| coronary artery bypass graft| collaborationMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care
The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a.Increase the setting on the suction. b.Notify the provider immediately. c.Re-position the chest tube. d.Take the tubing apart to assess for clots.
ANS:BIf the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart.DIF:Applying/ApplicationREF:778KEY:Coronary artery bypass graft| critical rescue| chest tubes| cardiovascular systemMSC:Integrated Process: Communication and DocumentationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a.Administer intravenous diltiazem (Cardizem). b.Assess vital signs and level of consciousness. c.Administer sublingual nitroglycerin. d.Assess capillary refill and temperature.
ANS:BIn temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture. DIF:Applying/ApplicationREF:664KEY:Cardiac electrical conductionMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a."Fish oil is contraindicated with most drugs for CAD." b."The best source is fish, but pills have benefits too." c."There is no evidence to support fish oil use with CAD." d."You can reverse CAD totally with diet and supplements."
ANS:BOmega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate.DIF:Understanding/ComprehensionREF:761KEY:Coronary artery disease| lipid-reducing agents| supplements| patient educationMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Health Promotion and Maintenance
A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes? a.Obtain an electrocardiogram (ECG) now and in the morning. b.Give the client an aspirin. c.Notify the Rapid Response Team. d.Prepare to administer thrombolytics
ANS:BThe Joint Commission's Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provideris available. Thrombolytics may or may not be needed.DIF:Remembering/KnowledgeREF:766KEY:Coronary artery disease| Core Measures| The Joint CommissionMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a."I should wear a snug-fitting shirt over the ICD." b."I will avoid sources of strong electromagnetic fields." c."I should participate in a strenuous exercise program." d."Now I can discontinue my antidysrhythmic medication."
ANS:BThe client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.DIF:Applying/ApplicationREF:674KEY:Cardiac electrical conductionMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Health Promotion and Maintenance
A nurse is caring for four clients. Which client should the nurse assess first? a.Client with an acute myocardial infarction, pulse 102 beats/min b.Client who is 1 hour post angioplasty, has tongue swelling and anxiety c.Client who is post coronary artery bypass, chest tube drained 100 mL/hr d.Client who is post coronary artery bypass, potassium 4.2 mEq/L
ANS:BThe post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.DIF:Analyzing/AnalysisREF:774KEY:Coronary artery disease| critical rescue| medical emergencies| hypersensitivities| allergic reactionMSC:Integrated Process: Nursing Process: AnalysisNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. Whataction by the nurse is best? a.Administer oxygen at 2 L/min. b.Allow continued bathroom privileges. c.Obtain a bedside commode. d.Suggest the client use a bedpan.
ANS:BThis client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needsoxygen, a commode, or a bedpan.DIF:Applying/ApplicationREF:769KEY:Coronary artery disease| activity intolerance| vital signs| nursing assessmentMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a.Assess the client's pupillary responses. b.Request a neurologic consultation. c.Stop the infusion and call the provider. d.Take and document a full set of vital signs.
ANS:CA change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.DIF:Applying/ApplicationREF:768KEY:Coronary artery disease| neurologic system| critical rescue| Rapid Response Team| thrombolytic agentsMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment shouldthe nurse complete next? a.Pulmonary auscultation b.Pulse strength and amplitude c.Level of consciousness d.Mobility and gait stability
ANS:CA heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamicconsequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity.Although the other assessments should be completed, the client's level of consciousness is the priority.DIF:Applying/ApplicationREF:670KEY:Cardiac electrical conduction| vascular perfusionMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Reduction of Risk Potential
The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a."It constricts vessels, improving blood flow." b."It dilates vessels, which lessens the work of the heart." c."It increases the force of the heart's contractions." d."It slows the heart rate down for better filling."
ANS:CA positive inotrope is a medication that increases the strength of the heart's contractions. The other options are not correct.DIF:Remembering/KnowledgeREF:772KEY:Coronary artery disease| inotropic agents| patient educationMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a.Decreased intraocular pressure b.Increased heart rate c.Short period of asystoled d.Hypertensive crisis
ANS:CClients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.DIF:Applying/ApplicationREF:662KEY:Cardiac electrical conduction| medicationMSC:Integrated Process: Nursing Process: AnalysisNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? a.Administer oxygen therapy at 2 liters per nasal cannula. b.Provide the client with a sleeping pill to stimulate rest. c.Schedule periods of exercise and rest during the day. d.Ask unlicensed assistive personnel to help bathe the client
ANS:CClients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.DIF:Applying/ApplicationREF:658KEY:Cardiac electrical conductionMSC:Integrated Process: Teaching/LearningNOT:Client Needs Category: Physiological Integrity: Basic Care and Comfort
A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the client's sheets. What action should the nurse perform first? a.Assess the insertion site. b.Change the client's sheets. c.Put on a pair of gloves. d.Assess blood pressure.
ANS:CFor the nurse's safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves. DIF:Applying/ApplicationREF:771KEY:Standard Precautions| infection control| intra-arterial blood pressure monitoring| staffsafetyMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a.Blood pressure that is 20 mm Hg below baseline b.Oxygen saturation of 94% on room air c.Poor peripheral pulses and cool skin d.Urine output of 1.2 mL/kg/hr for 4 hours
ANS:CPoor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4hours is normal.DIF:Remembering/KnowledgeREF:772KEY:Coronary artery disease| critical rescue| nursing assessmentMSC:Integrated Process: Nursing Process: AnalysisNOT:Client Needs Category: Physiological Integrity: Reduction of Risk Potential
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a.1530 (3:30 PM) b.1600 (4:00 PM) c.1630 (4:30 PM) d.1700 (5:00 PM)
ANS:CThe Joint Commission's Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM).DIF:Remembering/KnowledgeREF:774KEY:Coronary artery disease| Core Measures| The Joint CommissionMSC:Integrated Process: Communication and DocumentationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care
Which action should the nurse take first? a.Begin external temporary pacing. b.Assess peripheral pulse strength. c.Ask the client what medications he or she takes. d.Administer 1 mg of atropine
ANS:CThis client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other.The nurse should assess the client's current medications first.DIF:Applying/ApplicationREF:658KEY:Cardiac electrical conduction| medications| adverse effectsMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation?a.The client has hyperkalemia causing irregular QRS complexes. b.Ventricular tachycardia is overriding the normal atrial rhythm. c.The client's chest leads are not making sufficient contact with the skin. d.Ventricular and atrial depolarizations are initiated from different sites.
ANS:DNormal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate adifferent source of initiation of depolarization. This finding on an electrocardiograph tracingis not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.DIF:Understanding/ComprehensionREF:649KEY:Cardiac electrical conductionMSC:Integrated Process: Nursing Process: AnalysisNOT:Client Needs Category: Physiological Integrity: Physiological Adaptation
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrialpressure of 0.5 mm Hg. What action by the nurse is most appropriate? a.Level the transducer at the phlebostatic axis. b.Lay the client in the supine position. c.Prepare to administer diuretics. d.Prepare to administer a fluid bolus.
ANS:DNormal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated. MSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care
A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate?(Click the media button to hear the audio clip.) a.Assess for further chest pain. b.Call the Rapid Response Team. c.Have the client sit upright. d.Listen to the client's lung sounds.
ANS:DThe sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should next assess the client's lung sounds. Assessing for chest pain is notdirectly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound.DIF:Applying/ApplicationREF:762KEY:Coronary artery disease| respiratory assessment| respiratory system| nursing assessmentMSC:Integrated Process: Nursing Process: AssessmentNOT:Client Needs Category: Physiological Integrity: Reduction of Risk Potential26
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a.Make sure the defibrillator is set to the synchronous mode. b.Administer 1 mg of intravenous epinephrine. c.Test the equipment by delivering a smaller shock at 100 joules. d.Ensure that everyone is clear of contact with the client and the bed.
ANS:DTo avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.DIF:Applying/ApplicationREF:668KEY:Cardiac electrical conduction| safetyMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
The nurse is preparing to change a client's sternal dressing. What action by the nurse is mostimportant?a.Assess vital signs. b.Don a mask and gown. c.Gather needed supplies. d.Perform hand hygiene.
ANS:DTo prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown arenot needed. The nurse should gather needed supplies, but this is not the priority.DIF:Applying/ApplicationREF:776KEY:Coronary artery disease| infection control| hand hygieneMSC:Integrated Process: Nursing Process: ImplementationNOT:Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below:What action by the nurse is most important?
a.Assess the client's blood pressure and level of consciousness
