Med Surg Success Test 1

The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement? 1. Notify the health-care provider. 2. Document that the pericarditis has resolved. 3. Ask the client to lean forward and listen again. 4. Prepare to insert a unilateral chest tube.

3. Ask the client to lean forward and listen again. Having the client lean forward and to the left using gravity to force the heart nearer to the chest wall, which allows the friction rub to be heard. The nurse should attempt to hear the friction rub in multiple ways before documenting that it is not heard.

The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation/perfusion (V/Q) scan.

1. An elevated B-type natriuretic peptide (BNP).

The client comes to the emergency department saying, "I am having a heart attack." Which question is most pertinent when assessing the client? 1. "Can you describe your chest pain?" 2. "What were you doing when the pain started?" 3. "Did you have a high-fat meal today?" 4. "Does the pain get worse when you lie down?"

1. "Can you describe your chest pain?"

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? 1. Notify the health-care provider immediately. 2. Elevate the head of the client's bed. 3. Document this as a normal and expected finding. 4. Administer morphine intravenously.

1. Notify the health-care provider immediately. Notifying the health care provider immediately is necessary because S3 indicates left ventricular failure and is potentially life threatening

Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."

2. "I should bake or grill any meats I eat."

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously.

2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. #1 is incorrect because morphine is administered IV not IM #5 Is incorrect because nitro is given sublingually, not subcutaneously

The client is admitted to the emergency department, and the nurse suspects a cardiac problem. Which assessment interventions should the nurse implement? Select all that apply. 1. Obtain a midstream urine specimen. 2. Attach telemetry monitor to the client. 3. Start a saline lock in the right arm. 4. Draw a basal metabolic panel (BMP). 5. Request an order for a STAT 12-lead ECG.

2. Attach telemetry monitor to the client. 3. Start a saline lock in the right arm. 5. Request an order for a STAT 12-lead ECG A saline lock is needed to administer medications IV so a saline lock in the right arm is appropriate

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.

2. Diaphoresis and cool clammy skin. Diaphoresis is a systemic reaction to the MI. The body vasoconstrics to shunt blood from the periphery to the trunk of the body and causes cold, clammy skin.

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? The client will: 1. Be able to ambulate in the hall by date of discharge. 2. Have an audible S1 and S2 with no S3 heard by end of shift. 3. Turn, cough, and deep breathe every two (2) hours. 4. Have a pulse oximeter reading of 98% by day two (2) of care.

2. Have an audible S1 and S2 with no S3 heard by end of shift. Reason: Audible S1 & S2 are normal for a heart with adequate output, an audible S3 may indicate left ventricular heart failure

The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. 4. Encourage client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. #4 is not a choice because the patient should be on a diuretic and urine should be more frequent & lighter

The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client's potassium level is 4.5 mEq/L.

2. The client has an apical pulse of 56.

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells (WBCs).

3. Troponin

The telemetry nurse notes a peaked T wave for the client diagnosed with congestive heart failure. Which laboratory data should the nurse assess? 1. CK-MB. 2. Troponin. 3. BNP. 4. Potassium.

4. Potassium Hyperkalemia will cause an elevated T wave therefore the nurse should check these laboratory data.

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client's apical pulse is 64. 2. The client's calcium level is elevated. 3. The client's telemetry shows occasional PVCs. 4. The client's blood pressure is 90/62.

4. The client's blood pressure is 90/62. the clients BP is low, and a calcium channel blocker would lower the pressure more.

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor.

2. Assess the client's chest dressing and vital signs. #4 is incorrect because a nurse should assess the patient first, not a machine

The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia to the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

1. "Chest pain is caused by decreased oxygen to the heart muscle." #1 is correct because it is in layman's terms, #2 is incorrect because it is in medical terms

The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bedrest. Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."

1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." The heart tissue is dead, stress or activity may cause heart failure, and it does take about 6 weeks for scar tissue to form. #4 is incorrect because this is a condescending response, telling a patient that they are in danger is inappropriate.

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and capillary refill time <3 seconds.

1. Apical pulse rate of 110 and 4+ pitting edema of feet.

The client's telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client's cardiac enzymes.

1. Document this as normal sinus rhythm.

The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? 1. Instruct client to keep a diary of activity, especially when having chest pain. 2. Discuss the need to remove the Holter monitor during a.m. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor.

1. Instruct client to keep a diary of activity, especially when having chest pain. The holter monitor is a 24-hour electrocardiogram and the client must keep an accurate record of activity so that the health-care provider can compare the ECG recordings with different levels of activity. #2 is not the answer because the monitor should not come off for any reason

The client with coronary artery disease is prescribed transdermal nitroglycerin, a coronary vasodilator. Which behavior indicates the client understands the discharge teaching concerning this medication? 1. The client places the medication under the tongue. 2. The client removes the old patch before placing the new. 3. The client applies the patch to a hairy area. 4. The client changes the patch every 36 hours.

2. The client removes the old patch before placing the new.

The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm. 5. Keep the client in the supine position.

1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm. All of the above are necessary after a pericardiocentesis except keeping the patient in a supine position. Patient must be semi-fowlers.

The client diagnosed with an ST elevation myocardial infarction (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which should the nurse implement *first*? 1. Notify the healthcare provider. 2. Assess what the client ate at the last meal. 3. Request a STAT 12 lead echocardiogram. 4. Administer furosemide IVP.

1. Notify the healthcare provider. "Has developed" indicates a new issue; the nurse should notify the HCP of the assessment findings, which indicates the patient is in heart failure. #4 is incorrect because it is not what should be done first, although furosemide may be an intervention.

Which data would cause the nurse to question administering digoxin to a client diagnosed with congestive heart failure? 1. The potassium level is 3.2 mEq/L. 2. The digoxin level is 1.2 mcg/mL. 3. The client's apical pulse is 64. 4. The client denies yellow haze.

1. The potassium level is 3.2 mEq/L. The potassium level is below normal levels. hypokalemia can potentiate digoxin toxicity and lead to cardiac dysrhythmias.

The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis? 1. "Have you had a sore throat in the last month?" 2. "Did you have rheumatic fever as a child?" 3. "Do you have a family history of carditis?" 4. "What over-the-counter (OTC) medications do you take?"

2. "Did you have rheumatic fever as a child?" Rheumatic fever is an autoimmune response that can cause peridcarditis

The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first? 1. Call a code immediately. 2. Assess the client for a pulse. 3. Begin chest compressions. 4. Continue to monitor the client.

2. Assess the client for a pulse. The nurse must first determine if the client has a pulse. Pulseless catch is treated with defibrillation. Vtach with a pulse is treated with cardioversion.

The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high Fowler's position. 4. Assess the gag reflex prior to feeding the client.

2. Assess the client's neurovascular status. The nurse should make sure blood is circulating properly & check for the 6 P's.

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.

2. Assess the client's serum potassium level.

The nurse identifies the concept of perfusion for a client diagnosed with congestive heart failure. Which assessment data *support* this concept? 1. The client has a large abdomen and a positive tympanic wave. 2. The client has paroxysmal nocturnal dyspnea. 3. The client has 2+ glucose in the urine 4. The client has a comorbid condition of MI

2. The client has paroxysmal nocturnal dyspnea. Dyspnea occurring at night when the client is in recumbent position indicates that cardiac muscle is not able to compensate for extra fluid returning to the heart during sleep.

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately.

2. Stop the activity immediately and rest.

The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops. 2. Teach the client how to prevent orthostatic hypotension. 3. Encourage the client to eat bananas to increase potassium level. 4. Explain the importance of taking the medication with food.

2. Teach the client how to prevent orthostatic hypotension.

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays?" 3. "Are you sexually active?" 4. "Have you had any weight change?"

3. "Are you sexually active?" Sexual activity is a risk factor for angina resulting from coronary artery disease. The client's being elderly should not affect the nurse's assessment of the clients concerns about sexual activity.

Which client would most likely be misdiagnosed for having a myocardial infarction? 1. A 55-year-old Caucasian male with crushing chest pain and diaphoresis. 2. A 60-year-old Native American male with an elevated troponin level. 3. A 40-year-old Hispanic female with a normal electrocardiogram. 4. An 80-year-old Peruvian female with a normal CK-MB at 12 hours.

3. A 40-year-old Hispanic female with a normal electrocardiogram. Misdiagnosed clients often present atypical symptoms, they tend to be female, younger than 55, and in a minority group.

The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapy.

3. Cardiac rehabilitation.

Which preprocedure information should be taught to the female client having an exercise stress test in the morning? 1. Wear open-toed shoes to the stress test. 2. Inform the client not to wear a bra. 3. Do not eat anything for four (4) hours. 4. Take the beta blocker one (1) hour before the test.

3. Do not eat anything for four (4) hours. NPO decreases aspiration in case of emergency.

The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40 ̊F. 4. Wear open-toed shoes when ambulating.

3. Do not walk outside if it is less than 40 ̊F. When it is cold outside, vasoconstriction occurs, and this decreases oxygen to the heart muscle, therefore the client should not exercise in the cold.

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram. 3. Have the client sit down immediately. 4. Assess the client's vital signs.

3. Have the client sit down immediately.

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? 1. The client's peripheral pitting edema has gone from 3+ to 4+. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform ADLs without dyspnea. 4. The client has minimal jugular vein distention.

3. The client is able to perform ADLs without dyspnea.

The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the UAP to stop encouraging the leg movements. 2. Report this behavior to the charge nurse as soon as possible. 3. Praise the UAP for encouraging the client to move legs. 4. Take no action concerning the UAP's behavior.

3. Praise the UAP for encouraging the client to move legs. The nurse should praise and encourage UAP's to participate in the client's care. Clients on bedrest are at risk for DVT and moving the legs helps prevent this from occurring.

The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client's right pedal pulse is 3+ and bounding.

3. The client is complaining of numbness in the right foot.

The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)-g sodium diet. 3. Weigh client daily. 4. Plan for frequent rest periods.

4. Plan for frequent rest periods. Scheduling rest periods allows the client to participate in his or her own care and addresses a desired outcome.

The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client *needs more* teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."

4. "If my chest pain is not gone with one tablet, I will go to the ER." The client should take one tablet every 5 minutes and if no relief occurs after the third tablet, they need to be driven to the ER or call 911. #3 is incorrect because they should carry nitro with them at all times

Which population is at a higher risk for dying from a myocardial infarction? 1. Caucasian males. 2. Hispanic females. 3. Asian males. 4. African American females.

4. African American Females African Americans are more likely to die from MIs than any other populations

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position.

4. Assist the client to a sitting position

The nurse enters the client's room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. THe concept of perfusion is identified by the nurse. Which should the nurse implement *first*? 1. Notify the health care provider 2. Call a rapid response team (RRT) 3. Determine the telemetry monitor reading. 4. Push the code blue button.

4. Push the code blue button. The first action is to immediately notify the code team and initiate CPR per protocol.

The client is three (3) hours post-myocardial infarction. Which data would warrant immediate intervention by the nurse? 1. Bilateral peripheral pulses 2+. 2. The pulse oximeter reading is 96%. 3. The urine output is 240 mL in the last four (4) hours. 4. Cool, clammy, diaphoretic skin.

4. Cool, clammy, diaphoretic skin. Cold clammy skin is an indicator of carcinogenic shock which is a complication of MI and warrants immediate intervention

The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one (1) full minute. 2. Notify the client's cardiac surgeon. 3. Prepare the client for synchronized cardioversion. 4. Determine if the client is having pain.

4. Determine if the client is having pain. Sinus tach means the sinoatrial node is the main pacemaker and the rate is greater than 100 because of pain, anxiety, or fever.

The nurse is caring for a client who suddenly complains of crushing substernal pain while ambulating in the hall. Which nursing action should the nurse implement *first*? 1. Call a code blue. 2. Assess the telemetry reading. 3. Take the client's apical pulse. 4. Have the client sit down.

4. Have the client sit down.

The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching? 1. Be sure to allow for uninterrupted rest and sleep. 2. Refer client to outpatient occupational therapy. 3. Maintain oxygen via nasal cannula at two (2) L/min. 4. Discuss upcoming valve replacement surgery.

1. Be sure to allow for uninterrupted rest and sleep. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health.

The nurse is caring for a client diagnosed with coronary artery disease. Which should the nurse teach the client prior to discharge? 1. Carry your nitroglycerin tablets in a brown bottle. 2. Swallow a nitroglycerin tablet at the first sign of angina. 3. If one nitroglycerin tablet does not work in 10 minutes, take another. 4. Nitroglycerin tablets have a fruity odor if they are potent.

1. Carry your nitroglycerin tablets in a brown bottle.

The client diagnosed with a myocardial infarction (MI) is being discharged. Which discharge instructions should the nurse teach the client? 1. Call the health care provider if any chest pain happens. 2. Discuss when the client can resume sexual activity. 3. Explain the pharmacology of nitroglycerin tablets. 4. Encourage the client to sleep with the head of bed elevated.

2. Discuss when the client can resume sexual activity. The nurse should make sure the client is aware of when sexual activity can be safely resumed.

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.

2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. The probable cause of leg cramping is potassium excretion as a result of diuretic medications. Bananas and orange juice are high in potassium for a patient on diuretics.

The client has an implantable cardioverter defibrillator (ICD). Which discharge instructions should the nurse teach the client? 1. Do not lift or carry more than 23 kg. 2. Have someone drive the car for the rest of your life. 3. Carry the cell phone on the opposite side of the ICD. 4. Avoid using the microwave oven in the home.

3. Carry the cell phone on the opposite side of the ICD. Cell phones interfere with the functioning of the ICD if they are too close to it.

The nurse is administering morning medications to clients on a telemetry unit. Which medication would the nurse *question*? 1. Furosemide IVP to a client with a potassium level of 3.6 mEq/L. 2. Digoxin orally to a client diagnosed with rapid atrial fibrillation. 3. Enalapril orally to a client whose BP is 86/64 and apical pulse 65. 4. Morphine IVP to a client complaining of chest pain and who is diaphoretic.

3. Enalapril orally to a client whose BP is 86/64 and apical pulse 65. Enalopril an ACE inhibitor, will lower the blood pressure even more. The nurse should hold the medication and notify the HCP that the medication is being held.

The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client? 1. Explain the importance of tapering off the medication. 2. Discuss that the medication will make the client drowsy. 3. Instruct the client to take the medication with food. 4. Tell the client to take the medication when the pain level is around "8."

3. Instruct the client to take the medication with food. NSAIDS must be taken with food, milk, or antacids to reduce gastric distress #1 is incorrect because only steroids are tapered slowly, not NSAIDS

The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first? 1. The client with three (3) unifocal PVCs in one (1) minute. 2. The client diagnosed with coronary artery disease who wants to ambulate. 3. The client diagnosed with mitral valve prolapse with an audible S3. 4. The client diagnosed with pericarditis who is in normal sinus rhythm.

3. The client diagnosed with mitral valve prolapse with an audible S3. An audible S3 indicates left-sided heart failure and needs to be assessed immediately.

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain with inspiration and a nonproductive cough.

3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. this client is is exhibiting signs and symptoms of shock, the client is becoming unstable & needs an experienced nurse.

The unlicensed assistive personnel (UAP) tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first? 1. Tell the UAP to go take the client's vital signs. 2. Ask the UAP to have the telemetry nurse read the strip. 3. Notify the client's health-care provider. 4. Go to the room and assess the client's chest pain.

4. Go to the room and assess the client's chest pain. Assessment is the first step in the nursing process and should be implemented first, chest pain is a priority.

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit via a stretcher. 3. Provide the client going home discharge-teaching instructions. 4. Help position the client who is having a portable x-ray done.

4. Help position the client who is having a portable x-ray done.

The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client? 1. Pulsus paradoxus. 2. Complaints of fatigue and arthralgias. 3. Petechiae and splinter hemorrhages. 4. Increased chest pain with inspiration.

4. Increased chest pain with inspiration. Chest pain is the most common symptom of pericarditis, usually an abrupt onset and is aggravated by respiratory movements (coughing, change in movement, & swallowing)

The nurse is admitting a client diagnosed with coronary artery disease (CAD) and angina. Which concept is *priority*? 1. Sleep, rest, activity. 2. Comfort. 3. Oxygenation. 4. Perfusion

4. Perfusion The cardiac muscle is not perfused when there is a narrowing of the arteries caused by CAD or when an embolus or thrombosis occludes the artery. Adequate perfusion will supply oxygen to the cardiac muscle, allow for increased activity, and decrease pain. #1 Is incorrect because it is not a priority

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. A new graduate should be able to complete a pre procedure checklist and get this client to the cath lab

The client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this client? 1. Prepare for a pericardiocentesis. 2. Request STAT cardiac enzymes. 3. Perform a 12-lead electrocardiogram. 4. Assess the client's heart and lung sounds.

1. Prepare for a pericardiocentesis. Pericardiocentesis removes fluid from pericardial sac and is an emergency treatment for cardiac tamponade.

The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse? 1. Muffled heart sounds. 2. Nondistended jugular veins. 3. Bounding peripheral pulses. 4. Pericardial friction rub.

1. Muffled heart sounds. Muffled heart sounds are indicative to acute pericarditis

The nurse is transcribing the doctor's orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement? 1. Discuss the order with the health-care provider. 2. Take the client's apical pulse rate before administering. 3. Check the client's potassium level before giving the medication. 4. Determine if a digoxin level has been drawn.

1. Discuss the order with the health-care provider. This dosage is 10x the normal dose for a client with CHF and is potentially lethal.

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.

1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet. Low-fat/cholesterol diet helps prevent atherosclerosis Walking increases circulation Stress reduction is encouraged Increasing fiber in the diet will help remove cholesterol via GI system

The home health nurse is assigned a client diagnosed with heart failure. Which should the nurse implement? *Select all that apply:* 1. Request a dietary consult for a sodium-restricted diet. 2. Instruct the client to elevate the feet during the day. 3. Teach the client to weigh every morning wearing the same type of clothing. 4. Assess for edema in dependent areas of the body. 5. Encourage the client to drink at least 3,000 mL of fluid per day. 6. Have the client repeat back instructions to the nurse.

1. Request a dietary consult for a sodium-restricted diet. 2. Instruct the client to elevate the feet during the day. 3. Teach the client to weigh every morning wearing the same type of clothing. 4. Assess for edema in dependent areas of the body. 6. Have the client repeat back instructions to the nurse. #5 is incorrect because although fluids are encouraged, 3,000is excessive

The nurse has received shift report. Which client should the nurse assess *first* 1. The client diagnosed with coronary artery disease complaining of severe indigestion. 2. The client diagnosed with CHF who has 3+ pitting edema. 3. The client diagnosed with atrial fibrillation whose apical rate is 100 and irregular. 4. The client diagnosed with sinus bradycardia who is complaining of being constipated.

1. The client diagnosed with coronary artery disease complaining of severe indigestion. A complaint of indigestion could be cardiac chest pain. The nurse should assess this client because of the diagnosis of CAD and the word "severe" in the option.

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.

1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. An audible S3 indicates left ventricular heart failure and the nurse must assess this client first because it is an emergency situation

The nurse identifies the concept of tissue perfusion as a client problem. Which is an *antecedent* of tissue perfusion? 1. The client has a history of CAD 2. The client has a history of diabetes insidipidus 3. The client has a history of chronic obstructive pulmonary disease. 4. The client has multiple fractures from a motor-vehicle accident.

1. The client has a history of CAD CAD narrows the arteries of the heart, causing the tissues not to be perfused, especially when an embolus or thrombus occurs.

The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first? 1. Administer oxygen via nasal cannula. 2. Evaluate the client's urinary output. 3. Assess the client for cardiac complications. 4. Encourage the client to use the incentive spirometer.

3. Assess the client for cardiac complications. The nurse must assess to determine if pain is expected secondary to pericarditis or if the pain is indicative of a complication that requires intervention from the healthcare provider.

The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client's groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling.

3. The client refuses to keep the leg straight. If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood & the client could bleed to death very quickly, this requires immediate intervention.