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Which patient should the nurse assess first?
a. 2nd degree Mobitz 1
b. 1st degree AV block
c. occasional PVCs
d. ST elevation - ANSWERS-d. ST elevation
This indicates the pt is having a STEMI now
A client with diabetes is prescribed metoprolol for a heart disorder and a student nurse
is providing medication instruction. Which instruction will require the nursing instructor to
intervene?
a. "Sometimes this drug causes SOB, it should get better after about 2 weeks"
b. Rise slowly from a sitting or lying position
c. check your finger stick blood sugars closely and notify the HCP for elevated glucose
levels
d. check your radial pulse - ANSWERS-a. "Sometimes this drug causes SOB, it should
get better after about 2 weeks"
Metoprolol decreases the workload of the heart, which can lead to heart failure
,What fluid orders would the nurse question for a pt experiencing Hypovolemic shock?
SELECT ALL THAT APPLY.
a. LR
b. 0.9% NaCl
c. 0.45% NaCl
d. 0.25% NaCl
e. dextrose 5% in water - ANSWERS-c. 0.45% NaCl
d. 0.25% NaCl
e. dextrose 5% in water
isotonic and hypertonic fluids are indicated to replace volume
What EKG change would validate that a client is experiencing an acute MI?
a. loss of atrial (P) waves
b. ST-segment elevation
c. Sinus bradycardia
d. atrial flutter - ANSWERS-b. ST-segment elevation
A nurse is caring for a client in CCU and sees a rhythm that shows an elevated ST
segment. What will be the nurse's priority action?
a. administer O2 at 2-3 lpm
b. prepare to defibrillate
c. notify the HCP
d. administer a bolus of amiodarone - ANSWERS-a. administer O2 at 2-3 lpm
,STEMI indicates myocardial injury, applying oxygen will increase oxygenation to the
myocardium
Which medication will the nurse administer first receiving evening report?
a. the loading dose of antibiotic to the client diagnosed with endocarditis, possible
sepsis
b. the anti platelet medication to the client who had a MI
c. the coronary vasodilator patch to the client diagnosed with coronary artery disease
d. the statin medication to the client with atherosclerosis - ANSWERS-a. the loading
dose of antibiotic to the client diagnosed with endocarditis, possible sepsis
its a loading (1st) dose
The client on telemetry is having what appears to be Vtach. What will the RN on the
floor delegate to the UAP?
a. have the UAP to activate the code blue
b. ask the UAP to answer call lights on the unit
c. send the UAP to the client's room to start basic life support
d. ask the UAP to notify the client's HCP - ANSWERS-b. ask the UAP to answer call
lights on the unit
The nurse sees the rhythm strip of Vtach at the nursing desk. What will be the first
action of the nurse?
a. defibrillate the client
b. start CPR
c. assess for a pulse
d. cardiovert the client - ANSWERS-c. assess for a pulse
, A client admitted with chest pain is on amlodipine and atorvastatin at home. What items
on the food tray will the nurse remove?
a. apple juice
b. orange juice
c. cranberry juice
d. grapefruit juice - ANSWERS-d. grapefruit juice
The nurse is caring for clients on a cardiac unit. Which client will the nurse see first?
a. the client with angina who is reporting chest pain 3 out of 10
b. the client with CHF who has 3+ bilateral pedal edema
c. the client with endocarditis who has a temperature of 100 F
d. the client diagnosed with aortic valve stenosis who is complaining of being light-
headed - ANSWERS-a. the client with angina who is reporting chest pain 3 out of 10
A child has been admitted to the ICU after being diagnosed with a ventricular septal
defect. What assessment finding will confirm this medical diagnosis?
a. heart murmur
b. weight gain
c. breath sounds equal and clear
d. clubbed nails - ANSWERS-a. heart murmur
The patient is in V-fib and code blue has been activated. What setting with the nurse
use on the defibrillator?
a. cardiovert
b. pace