A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate? (Click the media button to hear the audio clip.)
a. Assess for further chest pain.
b. Call the Rapid Response Team.
c. Have the client sit upright.
d. Listen to the client's lung sounds.
Question 2The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse?
a. It constricts vessels, improving blood flow.
b. It dilates vessels, which lessens the work of the heart.
c. It increases the force of the heart's contractions.
d. It slows the heart rate down for better filling.
Question 3A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set,
by what time should the client have a percutaneous coronary intervention performed?
a.
1530 (3:30 PM)
b.
1600 (4:00 PM)
c.
1630 (4:30 PM)
d.
1700 (5:00 PM)
Question 4A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94 on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours
Question 5A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
a. Assess the IV site hourly.
b. Monitor the pedal pulses.
c. Monitor the client's vital signs.
d. Obtain consent for a central line.
Question 6A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals?
a. Dirty carpets in need of vacuuming
b. Expired food in the refrigerator
c. Old medications in the kitchen
d. Several cats present in the home
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