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
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 2 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 3 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.
Question 4 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 5 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.