AHN 447 Exam #1 (Multiple
Choice)Questions & Answers
A nurse is caring for four clients. Which client should the nurse assess first?
a. Client with an acute myocardial infarction, pulse 102 beats/min
b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety
c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr
d. Client who is post coronary artery bypass, potassium 4.2 mEq/L Correct Ans-B
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.
b. Ask the family if the client would like a fan in the room.
c. Keep the television tuned to the clients favorite channel.
d. Speak loudly to the client in case of hearing problems. Correct Ans-A
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?
a. Increase the setting on the suction.
b. Notify the provider immediately.
c. Re-position the chest tube.
d. Take the tubing apart to assess for clots. Correct Ans-B
,. 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?
a. Dirty carpets in need of vacuuming
b. Expired food in the refrigerator
c. Old medications in the kitchen
d. Several cats present in the home Correct Ans-B
. 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.
b. Monitor the pedal pulses.
c. Monitor the clients vital signs.
d. Obtain consent for a central line. Correct Ans-A
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that
a
significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours Correct Ans-C
,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?
a. 1530 (3:30 PM)
b. 1600 (4:00 PM)
c. 1630 (4:30 PM)
d. 1700 (5:00 PM) Correct Ans-B
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.
b. Call the health care provider or the Rapid Response Team.
c. Obtain a permit for an emergency temporary pacemaker insertion.
d. Prepare to administer antidysrhythmic medication. Correct Ans-A
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.
b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose
or sequential compression devices.
d. Have the client rate pain on a 0-to-10 scale and report to the nurse.
e. Take and record a full set of vital signs per hospital protocol. Correct Ans-ACE
, . 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
c. Lasts less than 15 minutes
d. No relief from taking nitroglycerin
e. Pain occurs without known cause Correct Ans-ABDE
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.)
a. Administer pain medication before ambulating.
b. Assist the client into a position of comfort in bed.
c. Encourage high-protein diet selections.
d. Provide complementary therapies such as music.
e. Remind the client to splint the incision when coughing. Correct Ans-BDE
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
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