ANSWERS (VERIFIED) | LATEST
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A nurse is assisting a client who will wear a Holter monitor for continuous cardiac
monitoring over the next 24 hours. The nurse takes which of the following actions to
assist this client?
Correct Answer: Gives the client a device holder to wear around the waist
A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the
client's record for which manifestation that differentiates pericarditis from other
cardiopulmonary problems?
Correct Answer: Pericardial friction rub
A client diagnosed with angina pectoris returns to the nursing unit after experiencing an
angioplasty. The nurse reinforces instructions to the client regarding the procedure and
home care measures. Which statement by the client indicates an understanding of the
instructions?
Correct Answer: "I need to adhere to my dietary restrictions."
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,A nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client
reports chest pain. When the administration of a sublingual nitroglycerin tablet as
prescribed does not relieve the chest pain, the next nursing action is to:
Correct Answer: Check the blood pressure and administer another nitroglycerin
tablet
A client has just returned from the cardiac catheterization laboratory. The left femoral
vessel was used as the access site. After returning the client to bed and collecting initial
data, the nurse places a sign above the bed stating that the client should remain on
bedrest:
Correct Answer: With the head of the bed elevated no more than 15 degrees
A nurse understands that which of the following is a correct guideline for adult
cardiopulmonary resuscitation (CPR) for a health care provider?
Correct Answer: Each rescue breath should be given over 1 second and should
produce a visible chest rise.
A client complaining of chest pain has an as-needed (PRN) prescription for sublingual
nitroglycerin (Nitrostat). Before administering the medication to the client, the nurse
should first check the client's:
Correct Answer: Blood pressure
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, A nurse is assisting in caring for a client in the telemetry unit and is monitoring the client
for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac
monitor indicates the presence of hypokalemia?
Correct Answer: ST-segment depression
A client has a history of left-sided heart failure. The nurse would look for the presence of
which of the following to determine whether the problem is currently active?
Correct Answer: Bilateral lung crackles
The client scheduled for a right femoropopliteal bypass graft is at risk for compromised
tissue perfusion to the extremity. The nurse takes which action before surgery to
address this risk?
Correct Answer: Marking the location of the pedal pulses on the right leg
A client seeks medical attention for intermittent episodes in which the fingers of both
hands become cold, pale, and numb. The client states that they then become reddened
and swollen with a throbbing, achy pain. The nurse further collects data on the client to
see whether these episodes occur with:
Correct Answer: Ingestion of coffee or chocolate
A nurse is caring for a client who is developing pulmonary edema. The client exhibits
respiratory distress, but the blood pressure is unchanged from the client's baseline. As
an immediate action before help arrives, the nurse would:
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