Question

Identify the rhythm below

Answer 1

Correct Answers:

Atrial Fibrillation

Rationale :

🔵 Atrial fibrillation is characterized by irregularly irregular rhythm with no visible P waves on ECG.

🔵 The baseline appears chaotic or fibrillatory, due to rapid atrial activity.

🔵 The ventricular response is irregular, depending on AV node conduction.

🔵 It is a common arrhythmia in elderly clients or those with cardiac conditions.

🔵 Atrial fibrillation increases risk for stroke due to clot formation in the atria.

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Answer 2

Correct Answers:

Morphine

Rationale :

🔴 Morphine helps relieve ischemic chest pain unrelieved by nitrates.

🔴 It also reduces preload and afterload, decreasing myocardial oxygen demand.

🔴 It acts as an anxiolytic, helping reduce stress-induced sympathetic drive.

🔴 Morphine can relieve pulmonary congestion by redistributing blood flow.

🔴 It is used cautiously due to respiratory depression and hypotension risk.

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Answer 3

Correct Answers:

Do not wear tight clothing over the insertion area
Count your pulse for 1 min each morning.
Request to be scanned with a handheld metal detector when in the airport.

Rationale :

🟡 Do not wear tight clothing over the insertion area – prevents pressure and irritation at the site.

🟡 Count your pulse for 1 min each morning – to detect pacemaker malfunction (bradycardia, loss of capture).

🟡 Request to be scanned with a handheld metal detector – safer than arch scanners; prolonged exposure to full-body scanners can affect function.

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Answer 4

Correct Answers:

Evaluating the client for nausea, vomiting, and anorexia

Rationale :

🟢 These are early signs of digoxin toxicity and must be evaluated before administration.

🟢 Digoxin has a narrow therapeutic range, and toxicity can lead to fatal arrhythmias.

🟢 Toxicity risk increases with hypokalemia, common in heart failure clients on diuretics.

🟢 Apical pulse should be taken for a full 60 seconds, not 30.

🟢 Potassium should not be restricted, as low levels increase toxicity risk.

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Answer 5

Correct Answers:

Eat foods that contain plenty of potassium.

Rationale :

🔷 Furosemide is a loop diuretic that causes potassium loss via the kidneys.

🔷 Low potassium can lead to muscle cramps, weakness, and dysrhythmias.

🔷 Clients should be taught to eat foods like bananas, oranges, and spinach.

🔷 Taking the drug at bedtime increases nocturia, so it's better taken in the morning.

🔷 Swelling should reduce, not increase, with diuretic therapy.

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Answer 6

Correct Answers:

Troponin I
CPK
Myoglobin
Troponin T

Rationale :

🔶 Troponin I and T – most specific cardiac markers, appear 4–6 hrs post-MI, peak at 12–24 hrs.

🔶 CPK (especially CK-MB) – rises within 4–8 hrs, though less specific than troponin.

🔶 Myoglobin – rises early (2–3 hrs) but is non-specific; useful for early detection.

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Answer 7

Correct Answers:

Obtain a 12-lead ECG.

Rationale :

🔵 A level of 6.8 mEq/L is severe hyperkalemia, which can cause fatal arrhythmias.

🔵 ECG changes include peaked T waves, widened QRS, and potentially asystole.

🔵 Monitoring cardiac status is the priority, even before lab confirmation.

🔵 Salt substitutes contain potassium chloride and are contraindicated.

🔵 Citrus fruits and bananas are high in potassium, not advised.

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Answer 8

Correct Answers:

Leg pain at rest

Rationale :

🟣 Rest pain indicates progression from intermittent claudication to critical limb ischemia.

🟣 It occurs when blood flow is inadequate even without activity.

🟣 Clients often report pain when elevating legs, and relief when legs are dependent.

🟣 Other expected findings include hair loss, shiny skin, thick nails, not flushed legs.

🟣 Legs are typically cool and pale, not warm or red unless dependent.

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Answer 9

Correct Answers:

Exertion and anxiety can trigger the pain.

Rationale :

🔴 Stable angina is triggered by increased myocardial oxygen demand—from exercise, stress, or emotion.

🔴 Pain is usually relieved by rest or nitroglycerin, not persistent.

🔴 It typically lasts <15 minutes, not >20 min (that suggests MI).

🔴 Sitting up may help with dyspnea, not necessarily anginal relief.

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Answer 10

Correct Answers:

“I must stop smoking"
“I am limiting my intake of fast foods"
“I will stop consuming alcohol."
“I need to monitor my weight."

Rationale :

🟢 Stop smoking – smoking accelerates atherosclerosis and platelet aggregation.

🟢 Limit fast foods – reduces saturated fat and LDL cholesterol intake.

🟢 Stop alcohol – excessive intake increases BP and triglycerides.

🟢 Monitor weight – obesity is a modifiable risk factor for CAD.

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Custom:Adult Health 2 Exam 2 West

No.

1 :
Identify the rhythm below

2 :
A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety?

3 :
A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.)

4 :
A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate

5 :
A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

6 :
A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)

7 :
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take/

8 :
A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

9 :
A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. Which of the following information should the nurse include about anginal pain?

10 :
A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

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Custom:Adult Health 2 Exam 2 West

No.

1 : Identify the rhythm below

2 : A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety?

3 : A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.)

4 : A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate

5 : A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

6 : A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)

7 : A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take/

8 : A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

9 : A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. Which of the following information should the nurse include about anginal pain?

10 : A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

1 :
Identify the rhythm below

2 :
A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety?

3 :
A nurse is teaching a client who is postoperative following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? (Select all that apply.)

4 :
A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate

5 :
A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

6 :
A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)

7 :
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take/

8 :
A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

9 :
A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. Which of the following information should the nurse include about anginal pain?

10 :
A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)