Rasmussen College: NUR2790 N3 E3 Guide 4 Latest updated 2021/2022
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. Wha...
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Rasmussen College: NUR2790 N3 E3 Guide 4 Latest updated
2021/2022
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. Aclient 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. Anursing 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 clientundergoing 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. Aclient 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. Aclient 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. Aclient 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. Aclient 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. Aclient 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. Anolder 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. Thenurse is preparing to change a clients sternal dressing. What action by the
nurse is most important?
d. Perform hand hygiene.
,13. Aclient 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 nurseis 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. Aclient 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. Aclient 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 nurseis 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. Aclient 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. Anurse 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. Aclient 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.
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