The intensive care department nurse is assessing t

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Question 1 of 5

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?

A. Notify the health-care provider immediately. B. Elevate the head of the client's bed. C. Document this as a normal and expected finding. D. Administer morphine intravenously.

Correct Answer: A

Rationale: An S3 heart sound post-MI (
A) indicates heart failure, requiring HCP notification. Elevating HOB (
B) is supportive, documenting as normal (
C) is incorrect, and morphine (
D) is for pain.

Question 2 of 5

The client diagnosed with a myocardial infarction asks the nurse, 'Why do I have to rest and take it easy? My chest doesn’t hurt anymore.' Which statement would be the nurse’s best response?

A. Your heart is damaged and needs about four (4) to six (6) weeks to heal.' B. There is necrotic myocardial tissue that puts you at risk for dysrhythmias.' C. Your doctor has ordered bedrest. Therefore, you must stay in the bed.' D. Just because your chest doesn’t hurt anymore doesn’t mean you are out of danger.'

Correct Answer: A

Rationale: Explaining that the heart needs 4–6 weeks to heal (
A) is accurate and understandable. Necrosis/dysrhythmias (
B) is technical, doctor’s orders (
C) dismiss patient autonomy, and danger (
D) is vague.

Question 3 of 5

The client with coronary artery disease asks the nurse, 'Why do I get chest pain?' Which statement would be the most appropriate response by the nurse?

A. Chest pain is caused by decreased oxygen to the heart muscle.' B. There is ischemia to the myocardium as a result of hypoxemia.' C. The heart muscle is unable to pump effectively to perfuse the body.' D. Chest pain occurs when the lungs cannot adequately oxygenate the blood.'

Correct Answer: A

Rationale: Chest pain in CAD is due to decreased oxygen to the heart muscle (
A), a clear explanation. Ischemia/hypoxemia (
B) is technical, pumping (
C) relates to heart failure, and lungs (
D) are incorrect.

Question 4 of 5

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease?

A. Assess the client's radial pulse. B. Assess the client's serum potassium level. C. Assess the client's glucometer reading. D. Assess the client's pulse oximeter reading.

Correct Answer: B

Rationale: Loop diuretics cause hypokalemia, which can precipitate dysrhythmias in CAD. Assessing potassium (
B) is critical. Pulse (
A), glucose (
C), and SpO2 (
D) are less directly related.

Question 5 of 5

The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement?

A. Perform isometric exercises daily. B. Walk for 15 minutes three (3) times a week. C. Do not walk outside if it is less than 40°F. D. Wear open-toed shoes when ambulating.

Correct Answer: B

Rationale: Walking 15 minutes 3 times a week (
B) is a safe, aerobic exercise for CAD. Isometric exercises (
A) increase BP, cold weather (
C) is a precaution, and open-toed shoes (
D) are irrelevant.

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Pediatric Cardiac Disorders NCLEX Questions Questions

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