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 B

Explanation

A. While potassium is typically diluted in IV fluids, the concentration and infusion rate must be clarified before administration. A standard dilution is 10 mEq in 100 mL or 40 mEq in 1L, but this must be verified.
B. Calling the physician for clarification is the safest step. IV potassium should never be given undiluted or as an IV push due to the risk of fatal cardiac arrhythmias.
C. IV push potassium is never appropriate as it can cause cardiac arrest.
D. Administering the undiluted 20 mEq/mL solution is dangerous and requires proper dilution before administration.

A. Amiodarone administration B. Defibrillation C. Epinephrine administration D. Synchronized Cardioversion

Correct Answer is B

Explanation

A. Amiodarone is an antiarrhythmic medication used after defibrillation and CPR in persistent ventricular fibrillation (VF) or ventricular tachycardia (VT). However, it is not the first priority.
B. Defibrillation is the immediate priority in a pulseless client with ventricular fibrillation. Early defibrillation increases the chances of survival. The shock should be delivered as soon as possible.
C. Epinephrine is given after the first defibrillation and CPR cycle, not before.
D. Synchronized cardioversion is inappropriate because it is used for unstable tachyarrhythmias with a pulse, not pulseless VF.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is ordered Potassium 40 mEq IV. On hand is Potassium Chloride 20 mEq/mL. What is the nurse’s next action?

Correct Answer is B

Explanation

A nurse is caring for a client with chest pain who becomes unresponsive. The client is pulseless and apneic. The code team places the client on the monitor, which indicates ventricular fibrillation. What is the next priority action?

Correct Answer is B

Explanation

A nurse is caring for a client with a possible acute myocardial infarction (AMI). The electrocardiogram (ECG) shows no ST segment elevations or depression. The nurse is aware that an elevation of which lab result will determine if there has been cardiac injury?

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?

Identify the following Cardiac Rhythm:

A nurse is caring for a client post-transcatheter aortic valve replacement (TAVR). During the first cardiac rehabilitation session, the client tells the nurse, "I do not need to be here. I am feeling so much better, I can do this at home." Which of the following is the appropriate nursing response?

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 caring for a patient with a history of hypertension. The client reports compliance with the prescribed thiazide medication but is complaining of generalized weakness and palpitations. The nurse should monitor the client for which potential complications of diuretics?

A Nurse is preparing to start a heparin drip on a client with acute coronary syndrome. Ordered: Give Heparin 1000 units per hour, standard dilution of 25,000 units in 250 mL of normal saline. What is the correct drip setting for the pump in mL/hr?

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.