ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 38 Questions
Question 1 of 5
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is an an intravenous infusion. The nurse is a client to respond, and now the client needs this medication. What response is the nurse is best.
Correct Answer: B
Rationale: After the original intracanoary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoulding. The other statements are not accurate. Heparin is not a blood thinner, although neurologist may refer is a not.
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
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 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 undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?
Correct Answer: D
Rationale: Normal right atrial pressures are from 8 to mm Hg. Lower pressures usually indicate hypvolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain levelled at the pilotboatatic axis. Positioning the nurse may use the client readings. Directions would be contraindicated.