Question set A: rhythm, infarct, and the failing pump

TIMING · 12 MINUTES Answer boxes left empty.

1. MC The monitor alarm sounds and the nurse enters the room of a client admitted with chest pain. The strip below is displayed. Which action does the nurse take first?

1. Deliver a precordial thump.
2. Palpate for a carotid pulse.
3. Start a second intravenous line.
4. Document the rhythm and continue to observe.

2. MC A client's twelve-lead shows ST elevation in leads II, III, and aVF. Ten minutes after the first sublingual nitroglycerin dose, the blood pressure falls from 148/86 to 82/50 mm Hg, the heart rate is 48, and the client feels lightheaded. Which action does the nurse take first?

1. Give the next scheduled sublingual nitroglycerin dose.
2. Withhold further nitrate, place the client supine, and notify the provider for volume support.
3. Administer the ordered intravenous opioid for the ongoing pain.
4. Raise the head of the bed to 60 degrees and reassess in fifteen minutes.

3. SATA A client with chronic heart failure is admitted for worsening symptoms. Which assessment findings indicate right-sided congestion? Select all that apply.

1. Jugular venous distention with the head of the bed at 45 degrees.
2. Bilateral dependent ankle edema with sacral edema when supine.
3. Pink frothy sputum.
4. Right upper quadrant tenderness with an enlarged liver.
5. Abdominal girth increased by 3 inches over four days.
6. Orthopnea relieved only by sleeping on three pillows.

4. ORD A client arrives at triage reporting undifferentiated chest pressure that began forty minutes ago. Place the nurse's first four actions in order.

1. Obtain the twelve-lead electrocardiogram.
2. Place the client on continuous cardiac monitoring and obtain full vital signs including oxygen saturation.
3. Establish intravenous access.
4. Administer chewable aspirin per protocol after screening for contraindications.

5. MC On the second day after abdominal surgery, a client reports right calf tenderness. The right calf measures 4 cm larger than the left at the marked point, and the skin is warm and pink. Which action does the nurse take first?

1. Massage the calf to promote venous return.
2. Ambulate the client in the hallway to relieve the discomfort.
3. Keep the limb still, notify the provider, and anticipate a venous ultrasound.
4. Apply a heating pad and elevate the leg above the level of the heart.

6. MC A 78-year-old is admitted for weakness and the strip below is obtained. The client is awake and conversational, blood pressure is 118/72 mm Hg, and there is no chest pain or shortness of breath. Which nursing action is the priority?

1. Prepare the client for immediate synchronized cardioversion.
2. Compare apical and radial pulses for a deficit and determine when the palpitations began.
3. Give the ordered rate-control medication before completing the assessment.
4. Place the client flat and apply oxygen at 6 liters per minute by mask.

7. SATA A client is being discharged after implantation of a cardioverter defibrillator. Which statements should be included in the teaching? Select all that apply.

1. Report a single shock followed by full recovery to the cardiologist.
2. Call emergency services for two or more shocks in a row, or for any shock with continuing symptoms.
3. A person touching you during a discharge may feel a tingle but will not be harmed.
4. Carry the device identification card and notify airport security before screening.
5. Magnetic resonance imaging is safe with every implanted defibrillator.
6. Keep a cell phone on the opposite side of the body and at least six inches from the device.

8. MC A client with a ventricular pacemaker programmed at 60 per minute has the strip below. Four spikes appear at the programmed interval; two are followed by a wide complex and two are followed by nothing. The measured rate is 42. What does the nurse document and report?

1. Failure to sense.
2. Failure to capture.
3. Normally functioning ventricular pacing.
4. Oversensing with appropriate pacemaker inhibition.

Margin notemark the two you guessed.

Rationales at → BOOK 08 · P13.

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