Question

The nurse cares for a client that has just been diagnosed with prehypertension. What is the priority nursing intervention?

Answer 1

Correct Answers:

Discuss modifiable risk factors.

Rationale :

🔶 Prehypertension is a warning stage where lifestyle modifications can significantly prevent the progression to full hypertension.

🔶 Discussing modifiable risk factors such as diet, physical activity, weight control, alcohol intake, and smoking cessation is a primary nursing intervention.

🔶 Early education empowers the client to take proactive measures and reduces the need for medication.

🔶 This approach supports primary prevention and aligns with evidence-based guidelines.

🔶 Clients need to understand the impact of sodium intake, stress management, and obesity on blood pressure control.

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Answer 2

Correct Answers:

Brain natriuretic peptide.

Rationale :

🔷 Brain natriuretic peptide (BNP) is a hormone released by the ventricles in response to increased pressure and volume overload, which are classic signs of heart failure.

🔷 Elevated BNP levels indicate fluid retention and ventricular strain, making it a highly specific marker for diagnosing and monitoring heart failure.

🔷 BNP assists in differentiating cardiac vs. pulmonary causes of dyspnea.

🔷 Serial BNP measurements can also guide therapy effectiveness and prognosis.

🔷 A level above 100 pg/mL is typically considered abnormal.

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Answer 3

Correct Answers:

Assess the client's blood pressure and heart rate.

Rationale :

🔴 A new onset of chest pain at rest rated 6/10 may indicate unstable angina or evolving myocardial infarction, requiring immediate assessment of vital signs.

🔴 Monitoring blood pressure and heart rate helps determine hemodynamic stability and guides urgent interventions.

🔴 This is a priority assessment using the ABC framework (Airway, Breathing, Circulation)—circulation comes first here.

🔴 Prompt vital sign monitoring allows the nurse to identify hypotension, bradycardia, or tachycardia, which may need immediate correction.

🔴 It precedes pain history, which is also important but not the first priority.

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Answer 4

Correct Answers:

Conduct the impulse to the ventricles for contraction

Rationale :

🟢 The Purkinje fibers are specialized fibers within the ventricular myocardium that rapidly conduct the cardiac impulse from the Bundle of His to the ventricular muscle.

🟢 This action enables coordinated ventricular contraction, which is essential for effective cardiac output.

🟢 These fibers are the final part of the electrical conduction system.

🟢 Proper functioning ensures the ventricles contract simultaneously, enhancing pumping efficiency.

🟢 Any damage can lead to ventricular arrhythmias or heart block.

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Answer 5

Correct Answers:

Lower the head of the bed and ensure the client is lying down.

Rationale :

🔵 Nitroglycerin causes vasodilation, which can result in a significant drop in blood pressure.

🔵 If hypotension occurs, the nurse should lower the head of the bed and place the client in a supine position to promote venous return and perfusion.

🔵 This intervention helps maintain cardiac output and reduces the risk of syncope or hypoperfusion.

🔵 Administering another dose would be inappropriate until the BP is stabilized.

🔵 Notify the provider if the hypotension persists.

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Answer 6

Correct Answers:

Teach the client how to monitor and record daily weight

Rationale :

⚫ Daily weight monitoring is a critical tool for assessing fluid retention in clients with congestive heart failure (CHF).

⚫ A gain of 2–3 lbs in a day or 5 lbs in a week may signal worsening heart failure and should prompt medical attention.

⚫ It allows for early detection of fluid overload, helping to adjust diuretic or dietary interventions.

⚫ Weights should be taken at the same time every morning, on the same scale, and in similar clothing.

⚫ This self-management strategy promotes client empowerment and early intervention.

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Answer 7

Correct Answers:

Administration of atropine IV push

Rationale :

🟡 Atropine is the first-line drug for symptomatic bradycardia as it increases heart rate by blocking parasympathetic stimulation of the SA node.

🟡 A heart rate of 32–48 bpm with syncope indicates hemodynamic compromise, requiring immediate intervention.

🟡 If atropine is ineffective, temporary pacing may be necessary.

🟡 Close cardiac monitoring is essential after administration due to the risk of arrhythmias or ischemia.

🟡 Other medications such as beta blockers or calcium channel blockers are contraindicated in bradycardia.

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Answer 8

Correct Answers:

Ischemia or medication toxicity

Rationale :

🟣 Junctional dysrhythmias can be caused by myocardial ischemia, especially affecting the SA node or AV node, leading the AV node to take over pacing.

🟣 Symptoms such as dizziness, anxiety, and hypotension result from reduced cardiac output due to bradycardia or ineffective rhythm.

🟣 Certain drugs like digoxin, beta-blockers, or calcium channel blockers can also suppress SA node activity, causing medication-induced junctional rhythms.

🟣 These rhythms are often seen in post-MI patients or those on AV node–depressing drugs.

🟣 Treatment involves addressing the underlying cause and improving perfusion.

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Answer 9

Correct Answers:

Ensure that everyone is clear of contact with the client and the bed.

Rationale :

🔴 Before defibrillation, it is crucial to ensure no one is in contact with the client or bed to prevent accidental electrical injury.

🔴 The nurse should loudly call out "CLEAR!" and visually check that no staff are touching the client.

🔴 This action prevents unintended harm during unsynchronized defibrillation, which is used for ventricular fibrillation (VF).

🔴 Synchronous mode is for cardioversion, not VF.

🔴 After clearing, the nurse can deliver the shock per ACLS protocols.

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Answer 10

Correct Answers:

"Cigarette smoking damages the lining of blood vessels. leading to the buildup of fatty deposits and narrowing of the arteries."

Rationale :

🟢 Cigarette smoking causes endothelial damage, promotes oxidation of LDL cholesterol, and enhances inflammatory processes that lead to atherosclerosis.

🟢 The damaged endothelium facilitates plaque buildup, which narrows the coronary arteries, reducing blood flow to the heart.

🟢 Smoking also promotes vasoconstriction, platelet aggregation, and reduced oxygen delivery to cardiac tissues.

🟢 These processes significantly increase the risk for coronary artery disease (CAD) and myocardial infarction.

🟢 Smoking cessation is one of the most effective interventions for CAD prevention.

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Exam 3 - Module 5

No.

1 :
The nurse cares for a client that has just been diagnosed with prehypertension. What is the priority nursing intervention?

2 :
The nurse is assessing a client who is experiencing manifestations of fluid overload related to heart failure. Which diagnostic test should the nurse anticipate to confirm the diagnosis?

3 :
A client with a history of angina reports new chest pain rated 6/10 while at rest. What is the nurse's priority assessment?

4 :
What is the role of the Purkinje fibers in the conduction system?

5 :
The nurse is caring for a client with unstable angina. The healthcare provider prescribes nitroglycerin for chest pain. After administering nitroglycerin, the nurse notes that the client's blood pressure has dropped from 140/85 mmHg to 100/60 mmHg. What is the nurse's priority action?

6 :
The nurse cares for a client with congestive heart failure (CHF). Which intervention should the nurse prioritize to improve the client's condition?

7 :
A telemetry nurse is assessing a client who was admitted with syncope and symptomatic bradycardia. The client's heart rate is fluctuating between 32-48 beats/minute. Which intervention should the nurse anticipate?

8 :
A client is admitted with junctional dysrhythmia and is exhibiting symptoms of anxiety, dizziness, and low blood pressure. What is the most likely cause of these symptoms?

9 :
The nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention should the nurse perform prior to defibrillating this client?

10 :
The nurse is educating a client about the health risks associated with cigarette smoking. Which explanation should the nurse provide to describe how cigarette smoking contributes to coronary artery disease?

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Exam 3 - Module 5

No.

1 : The nurse cares for a client that has just been diagnosed with prehypertension. What is the priority nursing intervention?

2 : The nurse is assessing a client who is experiencing manifestations of fluid overload related to heart failure. Which diagnostic test should the nurse anticipate to confirm the diagnosis?

3 : A client with a history of angina reports new chest pain rated 6/10 while at rest. What is the nurse's priority assessment?

4 : What is the role of the Purkinje fibers in the conduction system?

5 : The nurse is caring for a client with unstable angina. The healthcare provider prescribes nitroglycerin for chest pain. After administering nitroglycerin, the nurse notes that the client's blood pressure has dropped from 140/85 mmHg to 100/60 mmHg. What is the nurse's priority action?

6 : The nurse cares for a client with congestive heart failure (CHF). Which intervention should the nurse prioritize to improve the client's condition?

7 : A telemetry nurse is assessing a client who was admitted with syncope and symptomatic bradycardia. The client's heart rate is fluctuating between 32-48 beats/minute. Which intervention should the nurse anticipate?

8 : A client is admitted with junctional dysrhythmia and is exhibiting symptoms of anxiety, dizziness, and low blood pressure. What is the most likely cause of these symptoms?

9 : The nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention should the nurse perform prior to defibrillating this client?

10 : The nurse is educating a client about the health risks associated with cigarette smoking. Which explanation should the nurse provide to describe how cigarette smoking contributes to coronary artery disease?

1 :
The nurse cares for a client that has just been diagnosed with prehypertension. What is the priority nursing intervention?

2 :
The nurse is assessing a client who is experiencing manifestations of fluid overload related to heart failure. Which diagnostic test should the nurse anticipate to confirm the diagnosis?

3 :
A client with a history of angina reports new chest pain rated 6/10 while at rest. What is the nurse's priority assessment?

4 :
What is the role of the Purkinje fibers in the conduction system?

5 :
The nurse is caring for a client with unstable angina. The healthcare provider prescribes nitroglycerin for chest pain. After administering nitroglycerin, the nurse notes that the client's blood pressure has dropped from 140/85 mmHg to 100/60 mmHg. What is the nurse's priority action?

6 :
The nurse cares for a client with congestive heart failure (CHF). Which intervention should the nurse prioritize to improve the client's condition?

7 :
A telemetry nurse is assessing a client who was admitted with syncope and symptomatic bradycardia. The client's heart rate is fluctuating between 32-48 beats/minute. Which intervention should the nurse anticipate?

8 :
A client is admitted with junctional dysrhythmia and is exhibiting symptoms of anxiety, dizziness, and low blood pressure. What is the most likely cause of these symptoms?

9 :
The nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention should the nurse perform prior to defibrillating this client?

10 :
The nurse is educating a client about the health risks associated with cigarette smoking. Which explanation should the nurse provide to describe how cigarette smoking contributes to coronary artery disease?