Congestive Heart Failure
Myocardial Infarction
Coronary Artery Disease
"Priority"
Medications
100
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 should the nurse implement first? A. Sponge the client's forehead. B. Obtain a pulse oximetry reading. C. Take the client's vital signs. D. Assist the client to a sitting position.
D. Assist the client to a sitting position. Rationale: The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion.
100
Which cardiac enzyme with the nurse expect to elevate first in a client diagnosed with a myocardial infarction? A. Creatine kinase (CK-MB) B. Lactate dehydrogenase (LDH) C. Troponin D. White blood cells (WBCs)
C. Troponin Rationale: Troponin is the enzyme that elevates within 1 to 2 hours
100
The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin.Which statement indicates the client needs more teaching? A. "I should keep the tablets in the dark-color bottle they came in." B. "If the tablets do not burn under my tongue, they are not effective." C. "I should keep the bottle with me in my pocket at all times". D. "If my chest pain is not gone with one tablet, I will go to the ER".
D. "If my chest pain is not gone with one tablet, I will go to the ER". Rationale: The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, call 911.
100
The client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? A. Call a code. B. Call the healthcare provider. C. Check the clients status and lead placement. D. Press the recorder button on the electro cardiogram console.
C. Check the clients status and lead placement. Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly a electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cost and identify the appropriate intervention.
100
The nurse provides discharge instructions to a client who is taking warfarin sodium. Which statement, by the client, reflects the need for further teaching? A. "I will avoid alcohol consumption." B. "I will take my pills every day at the same time." C. "I have already called my family to pick up a medic alert bracelet." D. "I will take coated aspirin for my headaches because it will cut my stomach."
D. "I will take coated aspirin for my headaches because it will cut my stomach." Rationale: Aspirin containing products need to be avoided when a client is taking this medication
200
The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? A. The clients peripheral pitting edema has gone from 3+ to 4+. B. The client is able to take the radial pulse accurately. C. The client is able to perform an ADLs without dyspnea. D. The client has minimal jugular vein distention.
C. The client is able to perform an ADLs without dyspnea. Rationale: Being able to perform ADLs without dyspnea would indicate the clients condition is improving. The clients heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.
200
Along with persistent, cresting chest pain, which signs/symptoms would make the nurses suspect that the client is experiencing a myocardial infarction? A. Midepigastric pain and pyrosis. B. Diaphoresis and cool clammy skin. C. Intermittent claudication in pallor. D. Jugular vein distention and dependent edema.
B. Diaphoresis and cool clammy skin. Rationale: Diaphoresis is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.
200
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? A. "Chest pain is caused by decreased oxygen to the heart muscle." B. "There is a ischemia to the myocardium as a result of hypoxemia." C. "The heart muscle is unable to pump effectively to perfuse the body." D. "Chest pain occurs when he wants cannot adequately oxygenate the black."
A. "Chest pain is caused by decreased oxygen to the heart muscle." Rationale: This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain.
200
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? A. Sensation of palpitations. B. Causative factors, such as caffeine. C. Blood pressure and oxygen saturation. D. Precipitating factors, such as infection.
C. Blood pressure and oxygen saturation. Rationale: Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation.
200
The nurse is monitoring the client is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication? A. The development of complaints of insomnia. B. The development of audible expiratory wheezes. C. A baseline blood pressure of 150/80 mm Hg Followed by a blood pressure of 138/72 mm Hg after two doses of the medication D. A baseline resting heart rate of 88 beats/minute followed by a resting heart rate of 72 beats/minutes after two doses of the medication
B. The development of audible expiratory wheezes. Rationale: Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. Beta blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma.
300
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 us achieve this outcome? A. Measure intake and output. B. Provide 2 g sodium diet. C. Way the client daily. D. Plan for frequent rest periods.
D. Plan for frequent rest periods. Rationale: Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome.
300
The nurses caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. A. Administer morphine intramuscularly. B. Administer an aspirin orally. C. Apply oxygen via a nasal cannula. D. Place the client in a supine position. E. Minister nitroglycerin subcutaneously.
B. Administer an aspirin orally. C. Apply oxygen via a nasal cannula. Rationale: Aspirin is an antiplatelet medication and should be administered orally, oxygen will help decrease myocardial ischemia, thereby decreasing pain. Morphine should be given IV, supine position will increase respiratory effort, Nitroglycerin should be given sublingually.
300
Which intervention should the nurse implement when administering a loop diuretics to a client diagnosed with coronary artery disease? A. Assess the client's radial pulse. B. Assess the client's serum potassium level. C. Assess the clients glucometer reading. D. Assess the client's pulse oximeter reading.
B. Assess the client's serum potassium level. Rationale: Loop diuretics cost catastrophe and to be lost in the urine output. Therefore, the nurse should assess the clients potassium level, and if the client is hypokalemic, the nurse should questioning in ministering this medication.
300
The nurses caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? A. Anxiety level of the client and family. B. Presence of a medic alert card for the client to carry. C. Knowledge of restrictions on post discharge physical activity. D. Activation status of the device, heart rate cut off, and number of shocks it is program to deliver.
D. Activation status of the device, heart rate cut off, and number of shocks it is program to deliver. Rationale: The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether did the device is activated, the heart rate cut off above which it will fire, and the number shocks it is programmed to deliver.
300
The nurses planning to administer hydrochlorothiazide to a client. The nurse should monitor for which adverse effects related to the administration of this medication? A. Hypouricemia, Hypercalcemia B. Increased risk of osteoporosis C. Hypokalemia, hyperglycemia, sulfa allergy D. Hyperkalemia, hypoglycemia, penicillin allergy
C. Hypokalemia, hyperglycemia, sulfa allergy Rationale: Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also clients are at risk for hypokalemia and hyperglycemia.
400
The charge nurses making shift assignments for the medical floor. What's client should be assigned to the most experienced registered nurse? A. The client diagnosed with congestive heart failure who is being discharged in the morning. B. The client who is having frequent incontinent liquid bowel movements and vomiting. C. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. D. The client was complaining of chest pain with inspiration and nonproductive cough.
C. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62 Rational:This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client.
400
The nurses 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? A. The clients apical pulse is 64. B. The clients calcium level is elevated. C. The clients telemetry shows occasional PVCs. D. The client's blood pressure is 90/62.
D. The client's blood pressure is 90/62. Rationale: The clients blood pressure is low, a calcium channel blocker could cause the blood pressure to bottom out.
400
The elderly client has coronary artery disease. Which question should the nurse asked the client during the client teaching? A. "Do you have a daily bowel movement?" B. "Do you get here the chest x-rays?" C. "Are you sexually active?" D. "Have you had any weight change?"
C. "Are you sexually active?" Rationale: Sexual activity is a risk factor for angina resulting from coronary artery disease. The clients being elderly should not affect the nurses assessment of the client's concerns about sexual activity.
400
The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asked another nurse to contact the healthcare provider and prepares to implement which priority interventions? Select all that apply. A. Administering oxygen B. Inserting a Foley catheter C. Administering furosemide D. Administering morphine sulfate intravenously E. Transporting a client to the coronary care unit F. Place the client in a low Fowler's side-lying position
A. Administering oxygen B. Inserting a Foley catheter C. Administering furosemide D. Administering morphine sulfate intravenously Rationale: Pulmonary edema is a life threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, rapid acting diuretic, will eliminate accumulated. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing.
400
The nurse is monitoring a client is taking digoxin for adverse effects. Which findings are characteristic of digoxin toxicity? Select all that apply. A. Tremors B. Diarrhea C. Irritability D. Blurred vision E. Nausea and vomiting
B. Diarrhea D. Blurred vision E. Nausea and vomiting Rationale: Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting and diarrhea. Subsequent manifestations include headache and visual disturbances such as blurred vision
500
The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? A. The client diagnosed with myocardial infarction as an audible S3 heart sound. B. The client diagnosed with congestive heart failure has 4+ sacral pitting edema. C. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. D. The client with chronic real failure who has an elevated. creatinine level
A. The client diagnosed with myocardial infarction as an audible S3 heart sound. Rationale: And S3 heart sound indicates left ventricular failure, the nurse must assess this client first because it is an emergency situation.
500
The client diagnosed with a myocardial infarction is six (6) hours post right femoral percutaneous transluminal coronary angioplasty (PTCA), known as a balloon surgery. Which assessment data would require immediate intervention by the nurse? A. The client is keeping the affected extremity straight. B. The pressure dressing to the right femoral area is intact. C. The client is complaining of numbness in the right foot. D. The clients right pedal pulses is 3+ and bounding.
C. The client is complaining of numbness in the right foot. Rationale: Any neurovascular assessment data that isThe abnormal requires intervention by the nurse; numbness may indicate decreased blood supply to the right foot.
500
The nurses discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? A. Perform isometric exercises daily. B. Walk for 15 minutes three (3) times a week. C. Do not walk outside if it is less than 40° F. D. Wear open toed shoes when ambulating.
C. Do not walk outside if it is less than 40° F. Rationale: When it is cold outside, vasoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside
500
The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority? A. Ensure that the client has been intubated. B. Set the defibrillator to the "synchronize" mode. C. Administer in amiodarone bolus intravenously. D. Confirm that the rhythm is actually in ventricular fibrillation.
D. Confirm that the rhythm is actually in ventricular fibrillation. Rationale: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia.
500
Intravenous heparin in therapy as prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit A. Vitamin K B. Protamine sulfate C. Potassium chloride D. Aminocaproic acid
B. Protamine sulfate Rationale: The antidote for heparin is protamine sulfate; It should be readily available for use if excessive bleeding or hemorrhage should occur
M
e
n
u