MEDSURG 2 EXAM 2

A patient experiences mild chest pain during inspiration, while coughing, and while performing daily activities. Sitting in a forward position relieves the pain. The nurse identifies that the patient is experiencing what complication of myocardial infarction? Pericarditis Left-sided heart failure Ventricular aneurysm Papillary muscle dysfunction

Pericarditis

Ventricular fibrillation is identified in an unresponsive 50-year-old client who has just arrived in the ED. Which action will you take first? 1. Defibrillate at 200 J. 2. Start cardiopulmonary resuscitation (CPR). 3. Administer epinephrine (Adrenalin) 1 mg IV. 4. Intubate and manually ventilate.

1

Which of the following actions is the appropriate initial response to a client coughing up pink, frothy sputum? 1. Call for help 2. Call the physician 3. Start an I.V. line 4. Suction the client

1

Which of the following symptoms is most commonly associated with left-sided heart failure? 1. Crackles 2. Arrhythmias 3. Hepatic engorgement 4. Hypotension

1

During the 48 hours after a myocardial infarction (MI), a nurse should assign the highest priority to monitoring the patient for what complication? Dysrhythmias Anxiety and fear Metabolic acidosis Medication side effects

1 Dysrhythmia

A client is seen in the clinic with shortness of breath & fatigue is being evaluated for a possible diagnosis of heart failure? Which laboratory result will be the most useful to monitor? 1. Serum potassium 2. B-type natriuretic peptide 3. BUN 4. Hematocrit

2

You are working in the emergency department (ED) when a client arrives complaining of substernal and left arm discomfort that has been going on for about 3 hours. Which of these laboratory tests will be most useful in determining whether you should anticipate implementing the acute coronary syndrome standard orders? 1. Creatine kinase MB level 2. Troponin I level 3. Myoglobin level 4. C-reactive protein level

2

You are ambulating a cardiac surgery client who has a telemetry cardiac monitor when another staff member tells you that the client has developed supraventricular tachycardia at a rate of 146 beats/min. In which order will you take the following actions? 1. Call the client's physician. 2. Have the client sit down. 3. Check the client's blood pressure. 4. Administer PRN oxygen by nasal cannula.

2, 4, 3, 1

A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. You note that no pulse is palpable in the left foot and that it is cold and pale. Which action should you take next? 1. Lower the client's left foot below heart level. 2. Administer oxygen at 4 L/min to the client. 3. Notify the client's physician about the change in status. 4. Reassure the client that embolization is common in endocarditis.

3

Acute pulmonary edema caused by heart failure is usually a result of damage to which of the following areas of the heart? 1. Left atrium 2. Right atrium 3. Left ventricle 4. Right ventricle

3

The nurse coming on duty receives the report from the nurse going off duty. Which of the following clients should the on-duty nurse assess first? 1. The 58-year-old client who was admitted 2 days ago with heart failure, BP of 126/76, and a respiratory rate of 21 breaths a minute. 2. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DNR order. 3. The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving IV heparin. 4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem).

4. The client with A-fib has the greatest potential to become unstable and is on IV medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then go to the 58-year-old client admitted 2-days ago with heart failure (her s/s are resolving and don't require immediate attention). The lowest priority is the 89-year-old with end stage right-sided heart failure, who requires time consuming supportive measures.

A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take? A. Have the client lie flat in bed. B. Keep the affected leg slightly flexed. C. Elevate the head of the bed 45°. D. Keep the client NPO for 4 hr.

A

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? A. Frothy sputum B. Dependent edema C. Nocturnal polyuria D. Jugular distention

A

A nurse is monitoring a client who is on telemetry. Which of the ff. findings on the ECG strip should the nurse recognize as normal sinus rhythm? a. The P wave falls before the QRS complex. b. The T wave is in the inverted position. c. The P-R interval measures 0.22 seconds. d. The QRS duration is 0.20 seconds.

A

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action? A. Notify the provider of the client's allergy. B. Attach a wrist band indicating the client's allergy. C. Ask the client if any other foods cause such a reaction. D. Notify the dietary department of the client's allergy.

A

The patient who has recently been experiencing runs of ventricular tachycardia suddenly loses consciousness. The patient is defibrillated, and the rate returns as the following. What should the nurse do first? A) Begin compressions B) Shock the client again immediately C) Prepare for intubation D) Administer adenosine

A

A patient had a cardiac catheterization and is now in the recovery area. What nursing interventions should be included in the plan of care? (Select all that apply). A. assessing the peripheral pulses in the affected extremity B. checking the insertion site for hematoma formation C. evaluating temperature and color in the affected extremity D. assisting the patient to the bathroom after the procedure E. assessing vital signs every 8 hours

A B C

The patient presents to the emergency department after having crushing chest pain for the past 5 hours. The ECG and laboratory work confirm suspicions of an acute myocardial infarction (AMI). Which findings would be the most conclusive that the patient is having an AMI? (Select all that apply.) A) ECG changes with ST-elevation B) Elevated CK-MB isoenzymes C) Elevated serum troponin levels D) Elevated urinary myoglobin level

A, B, C

Patients with a history of myocardial infarction should take which medications indefinitely? (Select all that apply.) a. ACE inhibitors b. Alteplase c. Aspirin d. Beta blockers e. Clopidogrel

A, C, D Patients who have had an MI should take ACE inhibitors, ASA, and beta blockers indefinitely to prevent recurrence and to minimize continuing cardiac remodeling. Alteplase is given during acute management, and clopidogrel is used during acute management and as an adjunct to reperfusion therapy.

The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply. A. Abrupt closure of the coronary artery B. venous insufficiency C. arterial occulsion D. retroperitoneal bleeding E. bleeding at the insertion site

A, C, D, E

Which of the following are typical signs and symptoms of pericarditis? (SATA) A. Fever B. Increased pain when leaning forward C. ST segment depression D. Pericardial friction rub E. Breathing in relieves the pain

A, D

A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply.) A. Check peripheral pulses in the affected extremity. B. Place the client in high-Fowler's position. C. Measure the client's vital signs every 4 hr. D. Keep the client's hip and leg extended. E. Have the client remain in bed up to 6 hr

A, D, E

A patient arrives in the emergency department complaining of chest pain that has lasted longer than 1 hour and is unrelieved by nitroglycerin. The patient's electrocardiogram reveals elevation of the ST segment. Initial cardiac troponin levels are negative. The patient is receiving oxygen via nasal cannula. Which drug should be given immediately? a. Aspirin 325 mg chewable b. Beta blocker given IV c. Ibuprofen 400 mg orally d. Morphine intravenously

ANS: A This patient shows signs of acute ST-elevation myocardial infarction (STEMI). Because cardiac troponin levels usually are not detectable until 2 to 4 hours after the onset of symptoms, treatment should begin as symptoms evolve. Chewable aspirin (ASA) should be given immediately to suppress platelet aggregation and produce an antithrombotic effect. Beta blockers are indicated but do not have to be given immediately. Ibuprofen is contraindicated. Morphine is indicated for pain management and should be administered after aspirin has been given.

A patient is admitted to the coronary care unit from the emergency department after initial management of STEMI. A primary percutaneous coronary intervention has been performed. The nurse notes an initial heart rate of 56 beats per minute and a blood pressure of 120/80 mm Hg. The patient has a history of stroke and a previous myocardial infarction. Which order will the nurse question? a. Aspirin b. Beta blocker c. Clopidogrel d. Heparin

ANS: B A beta blocker would be contraindicated in this patient, because it slows the heart, and this patient is already bradycardic. Aspirin, clopidogrel, and heparin are recommended in patients who have had a primary PCI.

A nurse is an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? a. First-degree AV block b. Atrial fibrillation c. Sinus bradycardia d. Sinus tachycardia

B

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? A. Different blood pressure in the upper limbs B. Different apical and radial pulses C. Differences between oral and axillary temperatures D. Differences in upper and lower lung sounds

B

When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Obtain the blood pressure. b. Attach the cardiac monitor. c. Assess the peripheral pulses. d. Auscultate the breath sounds

B

During a head-to-toe assessment, the nurse notes the apical pulse is 128 and irregular. The patient is not in any distress and does not have any history of dysrhythmia. The nurse contacts the physician for an order to obtain a 12-lead EKG. Which of the following rhythms does the nurse anticipate being diagnosed? A. Sinus bradycardia B. Atrial fibrillation C. Ventricular tachycardia D. Ventricular fibrillation E. Junctional escape rhythm

B

Which of the following discharge instructions for self-care should the nurse provide to a patient who has undergone a percutaneous transluminal coronary angioplasty (PTCA) procedure? A. refrain from sexual activity for one month B. monitor the site for bleeding or hematoma C. Normal activities of daily living can be resumed the first day post op D. cleanse the site with disinfectants and dress the wound appropriately

B

A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation Which of the following actions should the nurse take? (SATA) A. Keep the client NPO after midnight B. Inspect the electrode pads C. Wash the skin with plain water before placing the electrodes D. Instruct the client not talk during the test E. Administer an analgesic prior to the procedure

B, C, D

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply)? A Flushing B Ashen skin C Diaphoresis D Nausea and vomiting E S3 or S4 heart sounds

B, C, D, E

The nurse is performing an assessment of the patient's heart. Where would the nurse locate the apical pulse if the heart is in a normal position? A. left 2nd intercostal space at the midclavicular line B. Left intercostal space at the midclavicular line C. right 2nd intercostal space at the miclavicular line D. right 3rd intercostal space at the midclavicular line

B. Left intercostal space at the midclavicular line

A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? A. obtain family history B. auscultate lung fields C. obtain ECG D. assess all pulses

C

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? A: Attach the leads for a 12 lead EKG B: Obtain a blood sample C: Initiate Oxygen Therapy D: Insert the IV Catheter

C

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A. Slow B. Not palpable C. Irregular D. Bounding

C

A nurse is assessing a client who has infective endocarditis. Which of the following should be the priority for the nurse to report to the provider? a. Splinter hemorrhages to the nails b. Dyspnea c. fever d. Clusters of petechiae in the mouth

C

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the clients restored rhythm is symptomatic bradycardia? a. Epinephrine b. Magnesium c. Atropine d. Sodium bicarbonate

C

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate? A. Brachial pulse in the left arm B. Brachial pulse in the right arm C. Radial pulse in the left arm D. Radial pulse in the right arm

C

The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies ever having a heart attack. c. Bilateral crackles are auscultated in the mid-lower lobes. d. The patient has occasional premature atrial contractions (PACs).

C

Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block

C

Which of the following assessment findings by the nurse indicates RIGHT ventricular failure in a client? A. Crackles B. Pink frothy sputum C. Jugular vein distention D. Paroxysmal nocturnal dyspnea

C

The nurse is caring for a patient 24 hours after the patient was diagnosed with ST segment elevation myocardial infarction (STEMI). The nurse should monitor the patient for what complication of myocardial infarction (MI)? Unstable angina Cardiac tamponade Sudden cardiac death Cardiac dysrhythmias

Cardiac dysrhythmias The most common complication after MI is dysrhythmias, which are present in 80 percent of patients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

A client is being evaluated for a possible myocardial infarction. The nurse performs a 12-lead ECG for an episode of new chest pain. The nurse will monitor for which sign of acute myocardial injury? A. Prolonged QRS complex B. Prolonged PR interval C. PR depressions D. ST elevation

D

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety? A. Nitroglycerin B. Aspirin C. Oxygen D. Morphine

D

A patient in the emergency department has severe chest pain. The nurse administers morphine intravenously. The patient asks the nurse why morphine is given. Which response by the nurse is correct? a. "Morphine helps by reducing anxiety and relieving pain." b. "Morphine helps by reducing pain and dissolving clots." c. "Morphine helps by relieving pain and lowering blood pressure." d. "Morphine helps by relieving pain and reducing the cardiac oxygen demand."

D

After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain b. 56-year-old with variant angina who is to receive a dose of nifedipine (Procardia) c. 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge d. 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)

D

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Q waves on ECG b. Elevated troponin levels c. Fever and hyperglycemia d. Tachypnea and crackles in lungs

D

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? A.Chronic stable angina B.Left-sided heart failure C.Coronary artery disease D.Acute myocardial infarction

D

The client is admitted to the emergency department with the chief complaint of "my heart is racing." Upon initiated cardiac monitoring the nurse discovers the client has a sustained heart rate of 170 beats per minute. The nurse then assesses the client for which of the following? A. Increased cardiac output B. Increased preload C. Decrease afterload D. Decreased cardiac output

D

The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure? A. increase in the patient's resting heart rate B. increase in the patient's LOC C. decrease in arterial blood flow in relation to venous flow D. increase in the size of the artery's lumen

D

When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min b. Pedal pulses 1+ bilaterally c. Blood pressure 103/54 mm Hg d. Chest pain level 7 on a 0 to 10 point scale

D

A patient is admitted to the intensive care unit with a diagnosis of myocardial infarction. The patient is in stable condition. The nurse recognizes what common medications that are used to treat this condition? Select all that apply. Diuretics Stool softeners Prophylactic antibiotics Dual antiplatelet therapy Intravenous (IV) nitroglycerin Low molecular weight heparin (LMWH)

Dual antiplatelet therapy Intravenous (IV) nitroglycerin Low molecular weight heparin (LMWH) Drug therapy for myocardial infarction includes intravenous nitroglycerin, dual antiplatelet therapy (e.g., aspirin and clopidogrel), and systemic anticoagulation with either LMWH given subcutaneously or IV unfractionated heparin, which are the initial drug treatments of choice for acute coronary syndrome (ACS). Oral beta-adrenergic blockers are given after day two if there are no contraindications (e.g., heart failure, heart block, hypotension). Diuretics and prophylactic antibiotics are not appropriate at this time.

When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administrating? Oxygen, nitroglycerin, aspirin, and morphine Aspirin, nitroprusside, dopamine, and oxygen Nitroglycerin, lorazepam, oxygen, and warfarin Oxygen, furosemide, nitroglycerin, and meperidine

Oxygen, nitroglycerin, aspirin, and morphine The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. Furosemide, meperidine, nitroprusside, dopamine, lorazepam, and warfarin may be used later in the patient's treatment.

Which of the following symptoms might a client with right-sided heart failure exhibit? 1. Adequate urine output 2. Polyuria 3. Oliguria 4. Polydipsia

3. Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid retention, which causes oliguria.

Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions? 1. Pericarditis 2. Hypertension 3. MI 4. Heart failure

4

Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output? 1. Angina pectoris 2. Cardiomyopathy 3. Left-sided heart failure 4. Right-sided heart failure

4

Which of the following is a compensatory response to decreased cardiac output? 1. Decreased BP 2. Alteration in LOC 3. Decreased BP and diuresis 4. Increased BP and fluid retention

4

You have given morphine sulfate 4 mg IV to a client who has an acute MI. When you evaluate the client's response 5 minutes after giving the medication, which finding indicates a need for immediate further action? 1. Blood pressure decrease from 114/65 to 106/58 mm Hg 2. Respiratory rate drop from 18 to 12 breaths/min 3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

4

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? A. Anorexia B. Weight gain C. Breathlessness D. Distended abdomen

C

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the ff. appears on the monitor strip? a. Pacemaker spikes after each QRS complex b. Pacemaker spikes before each P wave c. Pacemaker spikes before each QRS complex d. Pacemaker spikes with each T wave

C

A nurse is planning care for a client who has a suspected myocardial infarction. Which of the following should the nurse administer first? A. Aspirin B. Nitroglycerin C. Oxygen D. Morphine Sulfate

C

The nurse monitors a patient for complications of myocardial infarction. The nurse auscultates a new murmur at the cardiac apex. Which treatment strategies are appropriate for inclusion in the patient's care plan? Select all that apply. Antiplatelets Short-term corticosteroids Cardiac surgery with mitral valve repair Intraaortic balloon pump (IABP) therapy Nonsteroidal antiinflammatory agents (NSAIDs)

Cardiac surgery with mitral valve repair Intraaortic balloon pump (IABP) therapy

A patient with a history of unstable angina reports a sudden onset of retrosternal chest heaviness and tightness, fatigue, shortness of breath, and nausea. What actions should the nurse take? Select all that apply. Obtain a 12-lead ECG. Administer sublingual nitroglycerin. Place the patient in a supine position. Apply high-flow oxygen by face mask. Auscultate for a pericardial friction rub.

Obtain a 12-lead ECG. Administer sublingual nitroglycerin Initial management of the patient with chest pain includes the following: Obtain a 12-lead ECG and start continuous ECG monitoring. Position the patient in an upright, not supine, position unless contraindicated, and initiate oxygen by nasal cannula (not high-flow by face mask) to keep oxygen saturation above 93%. Establish an intravenous (IV) route to provide an access for emergency drug therapy. Give sublingual nitroglycerin and aspirin (chewable). Morphine sulfate is given for pain unrelieved by nitroglycerin (NTG). Auscultating for a pericardial friction rub is not an appropriate action.

The nurse is examining the ECG of a patient who has just been admitted with a suspected myocardial infarction (MI). Which ECG change is most indicative of prolonged or complete coronary occlusion? Sinus tachycardia Pathologic Q wave Fibrillatory P waves Prolonged PR interval

Pathologic Q wave The presence of a pathologic Q wave, which often accompanies ST segment elevation myocardial infarction (STEMI), is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless and apneic. Which of the following actions is the nurse's priority? a. Defibrillation b. Airway management c. Epinephrine administration d. Amiodarone administration

a. Defibrillation The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm.

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the ff. prescriptions should the nurse clarify? a. Serim cardiac enzyme level b. MRI of the chest c. physical therapy d. Low-Sodium diet

B

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take? A. Instruct the client to perform range-of-motion exercises to his lower extremities. B. Perform neurovascular checks with vital signs. C. Ambulate the client 1 hr following the procedure. D. Restrict the client's fluid intake.

B

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defribrillator (ICD). Which of the ff. information should the nurse include? a. the client cannot travel by air due to security screening b. the client should hold his cell phone on the side opposite the ICD c. the client should avoid the use of small electric devices. d. the client can carry his ICD in a small pocket.

B

A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor for which of the following complications? A. Bradycardia B. Pulmonary embolism C. Peripheral vascular Disease D. Hypertension

B

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority? A. The client's ECG tracing shows irregular heart rate without P waves B. The client has an aPTT of 80 seconds C. The client experiences sudden weakness of one arm and leg D. The client's urine output is cloudy and odorous

C

A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take? A. Offer the client a light snack B. Measure the client's blood pressure C. Measure the client's apical pulse D. Weigh the client

C

A nurse is caring for a client who has infective endocarditis. Which of the following manifestation is the priority for the nurse to monitor for? a. Anorexia b. Dyspnea c. Fever d. Malaise

C

A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include? A. "You can resume regular exercise as soon as tomorrow." B. "The dressing should be changed within 12 hours of the procedure." C. "You will notice a small hematoma at the incision site." D. "Pain medication will not be necessary."

C

A nurse in an intensive care unit is caring for a client who had an acute myocardial infarction (MI) and had cardiac enzymes drawn. The nurse should know that the results of the cardiac enzyme studies help determine the: A. location of pulmonary congestion B. location of infarction C. size of infarction D. degree of myocardium damage

D

A nurse is assessing a client who has left-sided heart failure. which of the following findings should the nurse expect? a. Jugular venous distention b. Abdominal distension c. Dependent edema d. Hacking cough

D

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock

D

A patient admitted to the emergency department 24 hours ago with complaints of chest pain was diagnosed with a ST-segment-elevation myocardial infarction (STEMI). What complication of myocardial infarction should the nurse anticipate? A Unstable angina B Cardiac tamponade C Sudden cardiac death D Cardiac dysrhythmias

D

A patient diagnosed with STEMI is about to undergo a primary percutaneous coronary intervention (PCI). Which combination of pharmacotherapeutic agents will be given to augment this procedure? a. Beta blocker and nitroglycerin b. Abciximab and a fibrinolytic drug c. Angiotensin-converting enzyme (ACE) inhibitor and aspirin d. Heparin, aspirin, and clopidogrel

D