Exam (elaborations)
Cardiovascular part II(Heart Failure, myocardial infarction, dysrhythmias) (1)
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Cardiovascular part II(Heart Failure, myocardial infarction, dysrhythmias) (1)
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Cardiovascular part II(Heart Failure, myocardialinfarction, dysrhythmias)
"Rehabilitation will help me function as well as I physically can." - ANS-A nurse is caring for a
client who is recovering from a myocardial infarction (MI). The cardiologist refers him to cardiac
rehabilitation. Which statement by the client indicates an understanding of cardiac
rehabilitation?
a third heart sound (S3). - ANS-While auscultating the heart sounds of a client with heart failure,
the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse
should document this as
the client with heart failure who is having some difficulty breathing - ANS-After receiving the shift
report, a registered nurse in the cardiac step-down unit must prioritize the client care
assignment. The nurse has an ancillary staff member available to help care for the clients.
Which of these clients should the registered nurse assess first?
Dependent edema. - ANS-A client has been diagnosed with right-sided heart failure. The nurse
should assess the client further for:
history of cerebral edema - ANS-Prior to administering tissue plasminogen activator (t-PA), the
nurse should assess the client for which contradiction to administering the drug?
Control the pain and support breathing and oxygenation. - ANS-A nurse is caring for a client
with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting,
dyspnea, and substernal chest pain. Which is the priority intervention?
Notify the healthcare provider. - ANS-The nurse is reviewing the electrocardiogram of a client
who has elevated ST segments visible in leads II, III, and aVf. Which choice is the nurse's best
action?
elevated ST - ANS-A client calls the nurse to the room, reporting substernal chest pain that
radiates to the jaw. The nurse records a rhythm strip and monitors the client's vital signs. Which
graphic highlights the portion of the client's ECG complex that may become elevated above the
baseline, indicating myocardial infarction (MI)?
Begin telemetry monitoring. - ANS-A client comes to the emergency department reporting
severe substernal chest pain radiating down the left arm. The client is admitted to the coronary
care unit with a diagnosis of myocardial infarction (MI). Which should the nurse do first when the
client is admitted to the coronary care unit?
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