The nurse is interviewing a client with a complex cardiac history. Which questions related to the client's history are most important to ask? Select all that apply.

Are you allergic to any medications or foods?

Do you have any children?

How did your mother die?

Have you had shortness of breath or weight gain?

How would you describe your symptoms?

Answer and Explanation

Correct Answer : A,C,D,E

The questions related to the client's history that are most important to ask are:

How would you describe your symptoms?: This question is important to assess the client's current cardiac symptoms and determine the severity, duration, and nature of their symptoms. It helps the nurse to evaluate the client's cardiac status and determine appropriate interventions.

Are you allergic to any medications or foods?: This question is crucial to identify any potential allergies that could impact the client's cardiac care. It helps the nurse ensure that medications and interventions are safe for the client and prevent any adverse reactions.

How did your mother die?:This question is important to gather information about the client's family history of cardiac diseases and potential risk factors. Understanding the family history helps the nurse assess the client's genetic predisposition to cardiac conditions and plan appropriate interventions and screenings.

Have you had shortness of breath or weight gain? : This question is important to assess for symptoms of heart failure or fluid retention. Shortness of breath and weight gain can indicate fluid accumulation, which is a common symptom in cardiac conditions. It helps the nurse evaluate the client's cardiac function and determine the need for further interventions or medication adjustments.

Let's review the other options and explain why they are not the most important questions to ask:

Do you have any children?: While family history is important, specifically asking about children is not as relevant to the client's current cardiac condition. The focus should be on the client's own symptoms, medical history, and family history of cardiac diseases.

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Correct Answer is D

Explanation

Helping to position a client for a portable x-ray generally involves physically assisting the client in moving into the appropriate position or adjusting their body as needed. This task can be safely delegated to the UAP as long as they have received proper training on how to safely assist with positioning and have a clear understanding of the specific instructions provided by the radiology department.

Assisting the client to take the beta-blocker involves administering medication, which falls within the scope of nursing practice and requires the nurse's expertise in medication administration and monitoring the client's response.

Transporting the client to the intensive care unit via a stretcher involves moving the client to another unit and may require additional monitoring and coordination of care during the transfer. This task is best performed by the nurse, who can assess the client's stability, ensure appropriate documentation, and communicate effectively with the receiving unit.

Providing discharge-teaching instructions to the client going home requires the nurse to provide information about medications, wound care, follow-up appointments, and other important instructions. This task involves comprehensive education and assessment ofthe client's understanding, and is best performed by the nurse to ensure accurate and complete information is provided.

A. Pacer spikes are adequate in number. B. Pacer spikes occur directly before the P waves. C. Pacer spikes occur directly before the QRS waves. D. Pacer spikes occur on the T waves. E. The heart rate is within programmed parameters.

Correct Answer is ["D","E"]

Explanation

The traces that should require immediate follow-up by the nurse are:

● Pacer spikes occur directly before the T waves.

Pacer spikes occurring on the T waves indicate an issue with the pacemaker's timing or sensing. This could lead to inappropriate pacing or pacing during the refractory period, which can be detrimental to the client's heart function.

● The heart rate is outside of programmed parameters.

If the heart rate is outside of the programmed parameters set for the client's pacemaker, it may indicate a malfunction or failure of the device or a change in the client's cardiac status. It is important for the nurse to assess the client's condition and notify the healthcare provider for further evaluation and intervention.

Let's review the other options and explain why they do not require immediate follow-up:

Pacer spikes are adequate in number: This indicates that the pacemaker is delivering the appropriate number of electrical impulses as programmed. As long as the other parameters are normal, this finding does not require immediate follow-up.

Pacer spikes occur directly before the P waves: This is the desired and expected pattern for a pacemaker in normal sinus rhythm. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.

Pacer spikes occur directly before the QRS waves: This is also the desired and expected pattern for a pacemaker in clients with ventricular pacing. It indicates proper timing and coordination between the pacemaker and the client's intrinsic electrical activity.

The heart rate is within programmed parameters: If the heart rate falls within the programmed parameters set for the client's pacemaker, it indicates that the device is functioning appropriately in maintaining the desired heart rate.

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The nurse is interviewing a client with a complex cardiac history. Which questions related to the client's history are most important to ask? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse and unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?

Correct Answer is D

Explanation

The nurse is caring for a client with a pacemaker/ICD on a continuous cardiac monitor. Which trace should require immediate follow up by the nurse? Select all that apply

Correct Answer is ["D","E"]

Explanation

The nurse is interviewing a client with a complex cardiac history. Which questions related to the client's history are most important to ask? Select all that apply.

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