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NUR2790 N3 E3 Guide 4 VERIFIED
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NUR2790 N3 E3 Guide 4NUR2790 N3 E3 Guide 4
Chapter 38: Care of Patients with Acute Coronary Syndromes
MULTIPLE CHOICE
1. A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be
disoriented to person, place, and time. What action by the nurse is best?
c. Stop the infusion and call the provider.
2. A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an
intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response by the
nurse is best?
b. The heparin keeps that artery from getting blocked again.
3. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse
assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and
respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?
b. Allow continued bathroom privileges.
4. A nursing student is caring for a client who had a myocardial infarction. The student is confused because the
client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes
and healthy menu choices. What response by the faculty member is best?
a. Continue to educate the client on possible healthy changes.
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?
d. Prepare to administer a fluid bolus.
6. A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse
implement for this client?
b. Ensure the balloon does not remain wedged.
7. A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the
clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to
100/60 mm Hg. What action by the nurse is most appropriate?
b. Assess the client for bleeding.
8. A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client
is yelling at family members and tells the doctor to just get this over with when asked to sign the consent form. What
action by the nurse is best?
d. Tell the client that anxiety is common and that you can help.
9. A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since
moving into the guest bedroom. What response by the nurse is best?
a. Do you have any concerns about sexuality?
10. A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and
vomiting. What action by the nurse takes priority?
c. Maintain airway patency.
11. An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent
dysrhythmias. What action by the nurse is most appropriate?
a. Assess for any hemodynamic effects of the rhythm.
12. The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important?
d. Perform hand hygiene.
,NUR2790 N3 E3 Guide 4
13. A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the clients
sheets. What action should the nurse perform first?
c. Put on a pair of gloves.
14. A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg
15. A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What
response by the nurse is best?
b. The best source is fish, but pills have benefits too.
16. A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the
nurse is best to meet The Joint Commissions Core Measures outcomes?
b. Give the client an aspirin.
17. A nurse is caring for four clients. Which client should the nurse assess first?
b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety
18. A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and
agitated. What action should the nurse perform first for comfort?
a. Allow family members to remain at the bedside.
19. The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows
significantly. What action by the nurse is most important?
b. Notify the provider immediately.
20. A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after
a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals?
b. Expired food in the refrigerator
21. A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
a. Assess the IV site hourly.
22. A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a
significant complication has occurred?
c. Poor peripheral pulses and cool skin
23. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The
facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core Measures set, by what
time should the client have a percutaneous coronary intervention performed?
c. 1630 (4:30 PM)
24. The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse
explain the action of these drugs to the client and spouse?
c. It increases the force of the hearts contractions.
25. A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears
the following sound. What action by the nurse is most appropriate?
(Click the media button to hear the audio clip.)
d. Listen to the clients lung sounds.
26. A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as
shown below: What action by the nurse is most important?
a. Assess the clients blood pressure and level of consciousness.
, NUR2790 N3 E3 Guide 4
MULTIPLE RESPONSE
1. A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this
include? (Select all that apply.)
b. Hypertension
c. Obesity
d. Smoking
e. Stress
2. A nurse is 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.)
a. Assist the client to the chair for meals and to the bathroom.
c. Ensure the client wears TED hose or sequential compression devices.
e. Take and record a full set of vital signs per hospital protocol.
3. A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs
from stable angina in what ways? (Select all that apply.)
a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
d. No relief from taking nitroglycerin
e. Pain occurs without known cause
4. A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort
measures does the nurse include when caring for this client? (Select all that apply.)
b. Assist the client into a position of comfort in bed.
d. Provide complementary therapies such as music.
e. Remind the client to splint the incision when coughing.
5. A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would
include which topics? (Select all that apply.)
a. Advanced age
b. Diabetes
c. Ethnic background
e. Smoking
Chapter 45: Care of Critically Ill Patients with Neurologic Problems
MULTIPLE CHOICE
1. A client is in the emergency department reporting a brief episode during which he was dizzy, unable to
speak, and felt like his legs were very heavy. Currently the clients neurologic examination is normal. About
what drug should the nurse plan to teach the client?
b. Clopidogrel (Plavix)
2. A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider
ordered a test on my heart, how should the nurse respond?
a. Most of these types of blood clots come from the heart.
3. A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What
action by the nurse is most appropriate for this client?
d. Rotate the clients meal tray when the client stops eating.
4. A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family
is most important for the nurse to obtain?
d. Time of symptom onset
5. A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority?
b. Ensure that informed consent is on the chart.
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