The client is on nitroglycerin and reports chest pain. What is the nurse's priority action?

Correct Answer: D

Rationale: The correct answer is D: Notify the healthcare provider immediately. When a client on nitroglycerin reports chest pain, it could indicate a worsening condition or potential myocardial infarction. The nurse's priority is to notify the healthcare provider promptly for further assessment and intervention. Administering nitroglycerin (choice A) may not address the underlying cause of the chest pain. Administering morphine (choice B) may mask symptoms and delay appropriate treatment. Administering aspirin (choice C) is important in chest pain management but does not take priority over notifying the healthcare provider for further evaluation and guidance.

Correct Answer: C

Rationale: The correct answer is C) Clear lung sounds and decreased heart rate. In heart failure, the heart's inability to pump effectively leads to fluid buildup in the lungs, causing crackles or wheezes on auscultation. Clear lung sounds indicate improved gas exchange and reduced pulmonary congestion, reflecting successful treatment. Decreased heart rate suggests that the heart is functioning more efficiently, reducing the workload on the heart. Option A, weight loss and diuresis, may occur with successful heart failure treatment due to fluid removal, but it does not directly indicate improved cardiac function. Option B, warm skin and less fatigue, are not specific indicators of heart failure treatment success but may be related to general well-being. Option D, absence of chest pain and improved level of consciousness (LOC), are important outcomes but do not directly reflect the effectiveness of heart failure treatment. Educationally, understanding these indicators is crucial for nurses caring for patients with heart failure. Monitoring lung sounds and heart rate helps assess treatment effectiveness, guiding interventions and optimizing patient outcomes. This question reinforces the importance of recognizing key clinical indicators of heart failure improvement.

Correct Answer: D

Rationale: In this scenario, the most important information to communicate to the physician regarding the use of fibrinolytic therapy with tPA for a patient with acute myocardial infarction is option D) The patient has had continuous chest pain since 1:00 PM. The correct answer is D because the duration of chest pain is a critical factor in determining the eligibility for fibrinolytic therapy. The time frame of symptom onset is crucial as fibrinolytic therapy is most effective when administered within a specific window period from the onset of symptoms. Option A is incorrect because a history of alteplase use 8 months ago does not impact the current decision-making process for acute management of AMI. Option B is not directly relevant to the decision to administer fibrinolytic therapy. Option C, T wave inversions on the ECG, while important for diagnosing AMI, are not as time-sensitive as the duration of chest pain in determining the need for immediate fibrinolytic therapy. Educationally, understanding the time-sensitive nature of interventions in acute conditions like AMI is crucial for healthcare providers. Timely communication of critical information to the healthcare team can significantly impact patient outcomes, making it essential for healthcare professionals to prioritize and convey relevant details accurately and promptly.

Correct Answer: C

Rationale: In this scenario, option C, "The patient's vision is becoming 'fuzzy'," is the correct answer that would warrant notifying the physician. This symptom could indicate digoxin toxicity, as visual disturbances are a common sign. It is crucial to address this promptly to prevent serious complications. Option A, "The patient's apical pulse is 68 and very irregular," may be concerning due to the irregularity, but in a patient with atrial fibrillation on digoxin, an irregular pulse is expected. It is not necessarily an immediate cause for concern unless accompanied by other symptoms. Option B, "The patient takes the digoxin with meals," is incorrect as taking digoxin with meals does not raise immediate concerns; however, adherence to dosing instructions should still be reinforced for optimal drug effectiveness. Option D, "The patient has lung crackles that clear after coughing," is unrelated to digoxin therapy and suggests a potential respiratory issue that would require further assessment but is not directly related to the medication. Educationally, this question highlights the importance of recognizing early signs of digoxin toxicity, emphasizing the need for close monitoring of patients on this medication, especially the elderly. It also underscores the significance of assessing for drug-related side effects and differentiating them from unrelated symptoms for appropriate intervention.

Correct Answer: A

Rationale: The correct answer is A) Transesophageal echocardiography (TEE). In TEE, the nurse instructs the client to avoid eating or drinking until sensation and the gag reflex return because the procedure involves passing a probe through the mouth and into the esophagus to obtain detailed images of the heart. This requires the client to have a numb throat to prevent gagging during the procedure, hence the need to wait until sensation returns. Option B) Magnetic resonance imaging (MRI) does not require the client to avoid eating or drinking for an extended period of time. Option C) Echocardiography is a non-invasive test that does not involve any restrictions on eating or drinking. Option D) Cardiac catheterization involves inserting a catheter into a blood vessel but does not require the client to avoid eating or drinking for an extended period. In an educational context, understanding the specific instructions and preparations for different cardiovascular tests is crucial for nurses to ensure the safety and well-being of their patients. Educating nurses on the rationale behind these instructions helps them provide optimal care and support to clients undergoing cardiovascular procedures.