Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Myocardial infarction (MI) is suggested by chest pain radiating to the left arm, diaphoresis, shortness of breath, and epigastric discomfort. The pain described as "sharp, tight, and like indigestion" aligns with cardiac ischemia.
Administering oxygen helps improve myocardial oxygenation, reducing ischemia.
Aspirin 325 mg is a standard intervention in suspected MI to prevent further platelet aggregation and reduce the risk of worsening thrombosis in the coronary arteries.
Monitoring vital signs is critical to assess for hemodynamic stability and signs of worsening cardiac function (e.g., hypotension, tachycardia).
Monitoring ECG rhythm helps detect ST-elevation or other ischemic changes and assess for life-threatening arrhythmias.
Morphine may be used for chest pain, but it is now considered secondary to nitroglycerin and beta-blockers.
Verapamil is a calcium channel blocker used for rate control in arrhythmias but is not first-line for acute MI.
Platelet count and WBC count are not immediately relevant to MI management.
Serum glucose levels may be affected by stress but are not a primary concern in acute MI management.

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Correct Answer is C

Explanation

A. A new systolic murmur is more indicative of valvular dysfunction or a septal defect rather than pericardial effusion.
B. Diminished breath sounds may be associated with atelectasis or pleural effusion but are not a hallmark finding of pericardial effusion.
C. Diminished heart sounds occur due to fluid accumulation in the pericardial sac, which muffles heart tones and is a key sign of pericardial effusion.
D. Increased blood pressure is not characteristic of pericardial effusion. Instead, pericardial effusion can lead to cardiac tamponade, which typically causes hypotension.

A. First-degree AV block B. Sinus tachycardia C. Atrial fibrillation D. Sinus bradycardia

Correct Answer is C

Explanation

A. First-degree AV block is characterized by a prolonged PR interval but does not typically present with irregular palpitations or a pulse deficit.
B. Sinus tachycardia causes a rapid but regular rhythm, whereas atrial fibrillation is irregularly irregular.
C. Atrial fibrillation is the correct answer. It is characterized by an irregular heart rate, absence of distinct P waves on an ECG, and a pulse deficit due to ineffective atrial contractions leading to incomplete ventricular filling.
D. Sinus bradycardia presents as a slow, regular heart rate rather than a rapid, irregular rhythm with a pulse deficit.

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Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in a critical care unit who is 4 hours post-operative coronary artery bypass surgery. The nurse performs the reassessment and suspects the client may be developing a pericardial effusion. What assessment findings would the nurse note in this case?

Correct Answer is C

Explanation

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

Correct Answer is C

Explanation

A nurse is caring for a client diagnosed with heart failure and atrial fibrillation. The client reports feeling palpitations and shortness of breath. The nurse is aware that clients with atrial fibrillation are at risk for which complication?

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action?

A nurse is caring for a client with heart failure who takes furosemide (Lasix) 20 mg daily at home and is receiving 40 mg of furosemide (Lasix) IV daily in the hospital. The nurse is aware that this patient is at risk for which electrolyte imbalance?

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that their blood pressure readings of 124/84 mm Hg and 128/88 mm Hg place them in which of the following categories?

A nurse is caring for a client with right-sided heart failure. Which of the following symptoms should the nurse include in teaching the client about signs of worsening heart failure? (SELECT ALL THAT APPLY)

A nurse is assessing a client two months after mitral valve replacement. The client complains of malaise, anorexia, weight loss, chills, and fever. The nurse suspects the client may have endocarditis. What other assessment sign is associated with infectious endocarditis?

A nurse is providing discharge instructions for a client diagnosed with congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.