Which cardiac enzyme would the nurse expect to elevate first in
3. Troponin is the enzyme that elevates within 1 to 2 hours
a client diagnosed with a myocardial infarction?
Along with persistent, crushing chest pain, which signs/symptoms
would make the nurse suspect that the client is experiencing a
myocardial infarction? 2. Diaphoresis is a systemic reaction to the MI. The body vasocon-
1. Midepigastric pain and pyrosis stricts to shunt blood from the periphery to the trunk of the body;
2. Diaphoresis and cool clammy skin this in turn, leads to cold, clammy skin
3. Intermittent claudication and paloor
4. Jugular vein distention and dependent edema
The client diagnosed with rule-out myocardial infarction is expe-
riencing chest pain while walking to the bathroom. Which action
should the nurse implement first?
3. Stopping all activity will decrease the need of the myocardium
1. Administer sublingual nitroglycerin
for oxygen and may help decrease the chest pain.
2. Obtain a stat 12 Lead ECG
3. Have the client sit down immediately
4. Assess the client's vital signs
The nurse is caring for a client diagnosed with a myocardial
infarction who is experiencing chest pain. Which interventions
should the nurse implement first? Select All that Apply 2. Aspirin is an antiplatelet medication and should be administered
1. Administer morphine sulfate Intramuscularly orally.
2. Administer an aspirin orally 3. Oxygen will help decrease myocardial ischeima, thereby de-
3. Apply oxygen via nasal cannula creasing pain
4. Place the client in a supine position
5. Administer nitroglycerin subcutaneously
The client who has had a myocardial infarction is admitted to the
telementry unit from intensive care. Which referral would be most
3. Cardiac rehabilitation is the most appropriate referral. The client
appropriate for the client?
can start rehabilitation in the hospital and then attend an outpatient
1. Social worker
cardiac rehabilitation clinic, which includes progressive exercises,
2. Physical therapy
diet teaching, and classes on modifying risk factors.
3. Cardiac rehabilitation
4. Occupation therapy
The client is one day postoperative coronary artery bypass
surgery. The client complains of chest pain. Which intervention
should the nurse implement first? 2. The nurse must always assess the client to determine if the
1. Medicate the client with intravenous morphine chest pain that is occurring is expected post-operatively or if it is
2. Assess the client's chest dressing and vital signs a complication of surgery.
3. Encourage the client to turn from side to side
4. Check the client's telemetry monitor
The client diagnosed with a myocardial infarction is six hours
post-right femoral percutanous transluminal coronary angioplasty
(PTCA), also known as balloon surgery. Which assessment data
3. Any neurovascular assessment data that is abnormal requires
would require immediate intervention by the nurse?
intervention by the nurse; numbness may indicate decreased
1. The client is keeping the affected extremity straight
blood flow to the right foot
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
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. An S3 indicates left ventricular failure and should be reported
1. Notify the health-care provider immediately to the healthcare provider. It is a potentially life threatening com-
2. Elevate the head of the client's bed plication of a myocardial infarction
3. Document this as a normal and expected finding
4. Administer morphine intravenously
The nurse is administering a calcium channel blocker to the client
diagnosed with a myocardial infarction. Which assessment data 4. The client's blood pressure is low, and a calcium channel blocker
would cause the nurse to question administering this medication? could cause the blood pressure to bottom out.
1. The client's apical pulse is 64
2. The client's calcium level is elevated
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