11/21)
The nurse expects which of these laboratory test results to be elevated in a client
following an acute myocardial infarction? - answer-Creatine kinase (CK), troponin T and
I, and myoglobin
One week following a myocardial infarction, a patient complains to the nurse of fatigue.
The nurse notes that the patient is slightly short of breath and the pulse rate is 110
bpm. Which of the following actions by the nurse is best? - answer-Check for any
edema or weight gain
The nurse cares for the client diagnosed with an acute anterior wall myocardial
infarction (MI). Why does the nurse identify the administration of pain medication as a
priority in this client's care? - answer-pain will increase myocardial oxygen demand
An older man is admitted to the hospital with a diagnosis of heart failure (HF). Which of
the following findings is most characteristic of heart failure? - answer-pulse 110,
respirations 24, blood pressure 100/60
The nurse cares for a patient immediately after a femoral-to-popliteal bypass graft. The
nurse is most concerned if which of the following is observed? - answer-clammy skin
The nurse prepares discharge teaching for the client diagnosed with a myocardial
infarction (MI). Which client statement indicates to the nurse that the client understands
the instructions? - answer-"I will change my diet to reduce my fat intake to less than
30%."
Surgical repair of a congenital heart defect is performed on the 5-month-old infant.
Which measure is most important for the nurse to include in the postoperative care
plan? - answer-Elevate the client's head to reduce respiratory effort.
A client receiving verapamil in the sustained-release form reports a headache. Which
information does the nurse provide to the client? - answer-This medication often causes
headache
The nurse teaches the client diagnosed with hypertension about a low sodium diet.
Which comment is most indicative that the client requires further instruction? -
answer-"I don't use any salt and I will season my foods with ketchup or mustard."
The nurse instructor instructs a class about myocardial infarction (MI). The instructor
tells the class that oxygen is given to the client experiencing an MI to keep the heart
, muscle well-oxygenated. This is done to prevent which problem that the ischemic heart
muscle is likely to develop? - answer-fatal dysrhythmias
The nurse cares for the client diagnosed with heart failure. The client has an
intravenous (IV) infusion running at 60 drops per minute and receives 40 mg of
furosemide intravenously daily. The clients complains, "I am more tired than usual."
While the client sits in a chair, the nurse auscultates the lungs and notes crackles that
were not present earlier. Which initial nursing action is most appropriate? - answer-slow
the IV to a keep open rate
The nurse cares for the client diagnosed with acute myocardial infarction. The client's
skin is clammy, blood pressure is 85/50; client appears restless and anxious. Which
action should the nurse take first? - answer-administer analgesia as ordered
The nurse for the client diagnosed with myocardial infarction. Which would the nurse
identify as the most important social support system when the client goes through
treatment and rehabilitation? - answer-family members
The nurse cares for the client diagnosed with a recent myocardial infarction (MI)
involving the anterior wall of the left ventricle. Which assessment data might alert the
nurse that the client is developing left ventricular failure? - answer-pulmonary crackles
The nurse performs diet teaching for a client diagnosed with a myocardial infarction.
The nurse determines that teaching is effective if the client selects which of the
following? - answer-sliced turkey, green beans, pear
The nurse instructs the client diagnosed with elevated total cholesterol levels. Which
client statement indicates a need for further teaching? - answer-"Medication is the best
way to lower cholesterol"
The nurse instructs a client diagnosed with atrial fibrillation receiving lisinopril. Which
statement, if made by the client to the nurse, indicates the need for further teaching? -
answer-"I have switched to a salt substitute instead of iodized salt."
The nurse cares for the client diagnosed with myocardial infarction (MI). Which client
statement indicates to the nurse an understanding of lifestyle changes required due to
the MI? - answer-"I guess I won't be playing volleyball with the guys for a while. I need
to complete my cardiac rehabilitation program."
The nurse cares for the client diagnosed with acute myocardial infarction. Which
intervention is priority? - answer-administer oxygen
The client experiencing chest pain takes a nitroglycerin tablet sublingually. Five minutes
later, the client calls the nurse and asks what to do since there has been no relief.
Which is the nurse's best response? - answer-"take two nitroglycerin tablets in 5-minute
intervals as needed and seek medical attention is there is no relief."