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Q: myocardial infarction (MI). The nurse should alter the environment to ensure
that it is
Answer:
Low
stimulus, low stress
Q: The nurse observes the following rhythm on the cardiac monitor. (Refer to the
figure.) Which action should the nurse take first?
Answer:
Evaluate the client for hypotension and assess mental status.
Q: A nurse is setting up the bedside unit for a client being admitted to the nursing
unit from the emergency department with a diagnosis of coronary artery disease
(CAD). The nurse should place highest priority on making sure that which of the
following is available at the bedside?
Answer:
Oxygen tubing and flowmeter
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Q: A nurse is collecting data on a client who was just admitted to the hospital with a
diagnosis of
Answer:
coronary artery disease (CAD). The client reveals having been under a great deal of
stress
recently. Based on this finding, the nurse should: Explore with the client the sources
of
stress in life.
Q: A nurse is planning adaptations needed for activities of daily living for a client
with cardiac disease. The nurse would incorporate which of the following in
discussions with the client?
Answer:
Take in adequate daily fiber to prevent straining during a bowel movement
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Q: A client with a diagnosis of congestive heart failure is preparing for discharge to
home from the
Answer:
hospital. The nurse determines that the client is ready for discharge to home if the
client can:
Verbally describe the daily medications, doses, and times to be administered.
Q: A client returns to the nursing unit after an above-the-knee amputation of the
right leg. The
Answer:
nurse positions the client: With the foot of the bed elevated
Q: A nurse is assisting in caring for a client in the telemetry unit who is receiving
an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium
chloride. Which occurrence observed on the cardiac monitor indicates the
presence of hyperkalemia?
Answer:
Tall, peaked T waves
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Q: A client with coronary artery disease has selected guided imagery to help cope
with psychological stress. Which statement by the client indicates the best
understanding of this stress reduction measure?
Answer:
"The best thing about this is that I can use it anywhere, anytime."
Q: A client with no history of heart disease has experienced an acute myocardial
infarction and has been given thrombolytic therapy with tissue plasminogen
activator (t-PA). The nurse interprets that the client is likely experiencing a
complication of this therapy if which of the following occurs?
Answer:
Tarry stools
Q: A hospitalized client with a history of angina pectoris is ambulating in the
corridor. The client suddenly complains of severe substernal chest pain. The
nurse should take which action first?
Answer:
Assist the client to sit or lie down.