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 nurse is assessing a client who had a myocardial infarction. Upon asschatating heart sounds, the nurse should be a client who had a myocardial infarction. The nurse is most appropriate?
Correct Answer: D
Rationale: The sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should assess the client's lung sounds for signs of fluid overload, which is associated with heart failure. Assessing for chest pain is not directly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound.
Question 2 of 5
A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as down below. What action by the nurse is most important?
Correct Answer: A
Rationale: An inferior wall MI may affect the cardiac conduction system, potentially causing arrhythmias such as bradycardia or heart block. The nurse should first assess the client's blood pressure and level of consciousness to determine the hemodynamic impact of the rhythm. Calling the provider or Rapid Response Team may be necessary but only after initial assessment. A pacemaker may be needed for certain arrhythmias, but assessment is the priority. CPR is not indicated unless the client is in cardiac arrest.
Question 3 of 5
Which are modifiable risk factors for coronary artery disease? (Select all that apply.)
Correct Answer: B,C,D,E
Rationale: Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.
Question 4 of 5
A nurse is a caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP?) (Select all that apply.)
Correct Answer: A,C,E
Rationale: The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TED hose or sequential compression devices, and taking/recording vital signs. The incentive spirometer should be used every hour the day after surgery, but teaching is a nursing responsibility. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse for a more detailed assessment.
Question 5 of 5
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in which way? (Select all that apply.)
Correct Answer: A,B,C,D
Rationale: The pain of a myocardial infarction is typically accompanied by shortness of breath, feelings of fear or anxiety, lasts longer than 15 minutes, and is not relieved by rest or nitroglycerin, unlike stable angina. Stable angina is often triggered by exertion, but MI pain can occur at rest.