ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 38 : Care of Patients with Acute Coronary Syndromes Questions
Question 1 of 5
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?
Correct Answer: B
Rationale: A major complication related to intra-arterial blood pressure monitoring is hemorrhages from the insertion site. Since the vital signs are out of the normal range, are a chance, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest, the nurse first needs to assess for bleeding.
Question 2 of 5
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysparhythmic, and the nurse should be a symptom of the syndrome?
Correct Answer: A
Rationale: Older clients may have dysparhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysparhythmic before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.
Question 3 of 5
The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important?
Correct Answer: C
Rationale: Changing a sternal dressing requires maintaining a sterile environment to prevent infection, especially in a post-surgical client. Preparing a sterile field is the most important action to ensure sterility. Washing hands and wearing sterile gloves are part of the process but are secondary to establishing a sterile field. A mask and gown may be required depending on hospital protocol, but the sterile field is critical. Clean technique is not appropriate for this procedure.
Question 4 of 5
A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
Correct Answer: D
Rationale: The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 100 beats/min has increased oxygen demands but is just over the normal limit for heart rate. The two post-coronary artery bypass clients are stable.
Question 5 of 5
A nurse is teaching about a positive inotrope to a client and their spouse. Which statement by the nurse is most appropriate to explain the action of these drugs to the client and spouse?
Correct Answer: C
Rationale: A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct.