16. A nurse is caring for a client with myocardial infarction. The nurse recognizes that the most common complication in the client following myocardial infarction is:
20. HyperkalemiaAnswer B is correct.<br />Cardiac dysrhythmia is the most common complication in the client following myocardial infarction; Answers A and C do not relate to MI therefore they are incorrect. Answer D is incorrect because it is not the most common complication ff MI.<br />The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority by reporting:<br />Chest drainage of 150mL in the past hour<br />Confusion and restlessness<br />Pallor and coolness of the skin<br />Urinary output of 40mL per hour<br />Answer A is correct.<br />Chest drainage of 150mL in an hour is excessive and the doctor should be notified regarding possible hemorrhage. Answer B could be in response to pain, changes in oxygenation or the emergence from anesthesia, therefore it is incorrect. Answer C is incorrect because it is an expected finding in the client recently returning from a CABG. Answer D is within normal limits therefore it is incorrect.<br />The doctor has prescribed aspirin 325mg daily for a client with transient ischemic attack. The nurse explains that aspirin was prescribed to:<br />Prevent headache<br />Boost coagulation<br />Prevent cerebral anoxia<br />Decrease platelet aggregation<br />Answer D is correct.<br />Aspirin decrease platelet aggregation or clumping, thereby preventing clots. Answer A is incorrect because the low-dose aspirin will not prevent headache. Answers B and C are untrue statements; thereby they are incorrect.<br />The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at:<br />The third intercostal space Right of the sternum<br />The third intercostal space Left of the sternum<br />The fourth intercostal space beneath the sternum<br />The fourth intercostal space midclavicular line<br />Answer D is correct.<br /> The mitral valve is heard loudest at the fourth intercostal space midclavicular line, which is the apex of the heart. A is incorrect because it is the location for the aortic valve. B is incorrect because it is the location for the pulmonic valve; C is incorrect because it is the location for the tricuspid valve.<br />The physician has ordered nitroglycerin (NTG) buccal tablets for a client with a stable angina. The nurse knows that NTG:<br />Slows contraction of the heart<br />Dilates coronary blood vessels<br />Increase the ventricular fill line<br />Strengthens the contraction of the heart<br />Answer B is correct.<br />NTG is used to dilate coronary artery which provides improved circulation to the myocardium. Answers A, C and D describe the effects of digoxin not NTG. Therefore they are incorrect.<br />The nurse has been teaching the role of diet in regulating blood pressure to a client with Hypertension. Which meal selection indicates that the client understands the new diet?<br />Cornflakes, whole milk, banana and coffee?<br />Scrambled eggs, bacon, toast and coffee?<br />Oatmeal, apple juice, dry toast and coffee?<br />Pancakes, ham, tomato juice and coffee?<br />Answer C is correct.<br />The client should be placed on a low Sodium, Low cholesterol and high fiber diet. Oatmeal is low in sodium and high in fiber. A is incorrect because cornflakes and whole milk are higher in sodium and poor sources of fiber, B and D are incorrect choices because they contain animal proteins that are high in both cholesterol and sodium.<br />A child with Tetralogy of Fallot is scheduled for a modified Blalock Taussig procedure. The nurse understands that the surgery will:<br />Reverse the direction of the blood flow<br />Allow better blood supply to the lungs<br />Relieve pressure on the ventricles<br />Prevent the need for further correction<br />Answer B is correct.<br />The Modified Blalock Taussig procedure is a palliative procedure in which the subclavian artery is joined to the pulmonary artery, thus allowing more blood to reach the lungs. Answers A, C, and D contain inaccurate statements, therefore they are incorrect.<br />The nurse is caring for a client admitted with suspected myasthemia gravis. Which finding is usually associated with a diagnosis of MG.<br />Visual disturbances, including diplopia<br />Ascending paralysis and loss of motor dysfunction<br />Cogwheel rigidity and loss of coordination<br />Progressive weakness that is worse at the day’s end<br />Answer D is correct.<br />A is incorrect because it refers to multiple sclerosis; B is pertaining to the symptoms of Guillain Barre Syndrome therefore it is incorrect; and C refers to Parkinson’s disease.<br />The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirm a diagnosis of Myasthenia Gravis. The medication used to treat MG is:<br />Prostamine ( neostigmine)<br />Atropine (atropine sulfate)<br />Didronel ( etidronale)<br />Tensilon (edrephonium)<br />Answer A is correct.<br /> Prostamine is used to treat MG; B is incorrect since it is used to reverse the effects of neostigmine, C is also incorrect because the drug is unrelated to the treatment of MG and D is a test for MG that’s why it is incorrect.<br />A client scheduled for atherectomy asks the nurse about the procedure. The nurse understands that:<br />Plaque will be removed by rotational or directional catheters<br />Plaque will be destroyed by a laser<br />A ballon-tipped catheters will compress fatty lesions against the vessel wall<br />Medication will used to dissolve the build-up of plaque.<br />Answer A is correct.<br />Special rotational and directional catheter will be used to remove the plaque; Answer B is incorrect since it describes ablation, C is incorrect because it describes percutaneous transluminal coronary angioplasty and answer D refers to the lipid-lowering agents therefore it is incorrect. <br />The nurse caring for a client scheduled for an angiogram should prepare the client for the procedure by telling him to expect:<br />Dizziness as the dye is injected<br />Nausea and vomiting after the procedure is completed<br />A decrease heart rate for several hours after the procedure is completed<br />A warm sensation as the dye is injected<br />Answer D is correct.<br />The client undergoing an angiogram will experience a warm sensation as the dye is injected. Answers A,B, and C are not associated with angioigram.<br />Which of the following is associated with Right-sided heart failure?<br />Shortness of breath<br />Nocturnal polyuria<br />Daytime oligoria<br />Crackles in the lungs<br />Answer B is correct.<br />Increased voiding at night is a symptom of a right-sided heart failure. Answers A, C, and D are incorrect because they are symptoms of left-sided heart failure.<br />An infant with a ventricular septal defect is discharged with a prescription for lanoxin elixir 0.01mg PO q 12 hours. The bottle is labeled 0.10mg per ½ tsp. The nurse should instruct the mother to:<br />Administer the med using a nipple<br />Administer the med using the calibrated dropper in the bottle<br />Administer the med using a plastic baby spoon<br />Administer the med in a baby bottle with 1oz of water.<br />Answer B is correct.<br />The medication should be administered using the calibrated dropper that comes with the medication. Answer A and C are incorrect because part of all the med could be lost during administration and answer D is incorrect because part of the med will be lost if the child does not finish the bottle.<br />The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:<br />Hip<br />Ankle<br />Earlobe<br />Chin<br />Answer C is correct.<br />If the finger cannot be used the next best place to apply the oxygen monitor is on earlobe. It can also be on the forehead, but the choices in the answers A, B, and D will not provide the needed readings.<br />The client who is admitted with thrombophebitis has an order for heparin. The med should be administered using a/an?<br />Butetrol<br />Infusion catheter<br />Intravenous filter<br />Tree-way stop clock<br />Answer B is correct.<br />To safely administer the heparin, the nurse should obtain infusion controller. Too rapid infusion of heparin can result to hemorrhage. A, C, and D are incorrect. It is not necessary to have buretrol, an infusion filter or a three-way stop clock.<br />The nurse identifies ventricular tachycardia on the heart monitor. The nurse should immediately:<br />Administer atropine sulfate<br />Check the potassium level<br />Prepare to administer an antiarrhythmic such as lidocaine<br />Defibrilliate at 360 joules<br />Answer C is correct.<br /> The treatment for ventricular tachycardia is lidocaine. A precordial thump is sometimes successful in slowing the rate but this should be done only if a defibrillator is available.<br />In A, atropine sulfate will speed the rate further; B checking the potassium level is indicated but is not the priority. D Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation. Also, fibrillation should begin at 200 joules and be increased at 360 joules. <br />To ensure safety while administering a Nitroglycerin patch, the nurse should?<br />Wear gloves while administering the patch<br />Shave the area where the patch will be applied<br />Wash the area thoroughly with soap and rinse with hot water<br />Apply the patch to the buttock<br />Answer A is correct.<br />To protect herself, the nurse should wear gloves when applying a NTG patch or cream because it has sudden hypotension effect. Answer B is incorrect because shaving the skin might abrade the area. Answer C is also incorrect because washing with hot water will vasodilate and thereby increase absorption and the patches should be applied to area above waist, making answer D incorrect.<br />The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test? <br />Atropine sulfate<br />Furosemide<br />Prostigmin<br />Promethazine<br />Answer A is correct.<br />Atropine sulfate is the antidote for tensilon and is given to treat cholinergic crisis. Furosemide is a diuretic, prostigmin is the treatment for Myasthenia Gravis and promethazine is an antiemetic, antianxiety med. Thus B, C, and D are incorrect.<br />Which laboratory test would be the least effective in making the diagnosis of MI?<br />AST<br />Troponin<br />CK-MB<br />Myoglobin<br />Answer A is correct.<br />AST is not specific for MI. Answers B, C, and D are more specific, although myoglobin is also elevated in burns and trauma to muscles. <br />Which f the following roommates would be most suitablefor the client with Myasthenia Gravis?<br />A client with hypothyroidism<br />A client with Crohn’s disease<br />A client with pylonephritis<br />A client with bronchitis <br />Answer A is correct.<br />The most suitable room for the client with Myasthenia Gravis is the client with hypothyroidism because he is quiet. Answer B will be up to the bathroom frequently, C has a kidney infection and will be up to urinate frequently and D will be coughing and will disturb any roommate.<br />The client admitted to the emergency department with complaints of crushing chest pain that radiates to the left jaw. After obtaining a stat electrocardiogram the nurse should:<br />Obtain history of prior cardiac problems<br />Begin an IV using a large-bore catheter<br />Administer oxygen at 2L per minute via nasal cannula<br />Perform pupil checks for size and reaction to light<br />Answer C is correct.<br />The nurse should give priority to administering oxygen via nasal cannula. Answer A is incorrect because the history of prior cardiac problems can be obtained after the client’s condition has stabilized. Answer B is incorrect because starting an IV is done after the client’s oxygen needs are met. Answer D is incorrect because pupil checks are part of neurological assessment, which is not indicated for the situation.<br />A client is hospitalized with an acute myocardial infarction. Which nursing diagnosis reflects an understanding of the cause of acute Myocardial infarction?<br />Decreased cardiac output r/t damage to the myocardium<br />Impaired tissue perfusion r/t an occlusion in the coronary vessels<br />Acute pain r/t cardiac ischemia<br />Ineffective breathing patterns r/t decreased oxygen to the tissues<br />Answer B is correct.<br />The cause of myocardial infarction is occlusion in the coronary vessels by a clot or atherosclerotic plaque. Answer A and C are incorrect because they are the result, not the cause of acute myocardial infarction. Answer D is incorrect because it reflects a compensatory action in which the depth and rate of respirations changes to compensate for increased cardiac output.<br />A client is transferred to intensive care unit following a coronary artery bypass graft. Which one of the post-surgical assessments should be reported to the physician?<br />Urine output of 5omL in the past hour<br />Temperature of 99ºF<br />Strong pedal pulses bilaterally<br />Central venous pressure 15mmH2O<br />Answer D is correct.<br />The central venous pressure of 15mm H2O indicates fluid overload. Answers A, B, and C are incorrect because they are not reported a cause for concern; therefore they do not need to be reported to the physician.<br />A client has tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:<br />Loss of myelin sheath in portions of the brain and spinal cord<br />An interruption in the transmission of impulse from nerve endings to muscles<br />Progressive weakness and loss of sensation that begins in the lower extremities<br />Loss of coordination and stiff ‘cogwheel’ rigidity<br />Answer B is correct<br />Myasthenia Gravis is cause by a loss of acetylcholine receptors, which results in the interruption of the transmission of the nerve impulses from the nerve endings to muscles. Answer A is incorrect because it refers to multiple sclerosis. Answer C is incorrect because it refers to Gullian - Barre syndrome. Answer D is incorrect because it refers to Parkinson’s disease.<br />The physician has prescribed nitroglycerin sublingual tablets as needed for a client with angina. The nurse should tell the client to take medication:<br />After engaging in strenuous activity<br />Every 4 hours to prevent chest pain<br />As soon as he notices signs of chest pain<br />At bedtime to prevent nocturnal angina<br />Answer C is correct.<br />Nitroglycerin tablets should be used as soon as the client first notices chest pain or discomfort. Answer A is incorrect because the medication should be used before engaging in activity. Strenuous activity should be avoided. Answer B is incorrect because the medication should be used when pain occurs, not on a regular schedule. Answer D is incorrect because the medication will not prevent nocturnal angina. <br /> <br />
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