Angina,MI NCLEX Style Questions With

Angina,MI NCLEX Style Questions With Verified Answers

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction? - ANSWER 3. Troponin is the enzyme that elevates within 1 to 2 hours

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction?

• Midepigastric pain and pyrosis
• Diaphoresis and cool clammy skin
• Intermittent claudication and paloor
• Jugular vein distention and dependent edema - ANSWER 2. Diaphoresis is a systemic

reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this in turn, leads to cold, clammy skin

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?

• Administer sublingual nitroglycerin
• Obtain a stat 12 Lead ECG
• Have the client sit down immediately
• Assess the client's vital signs - ANSWER 3. Stopping all activity will decrease the need of

the myocardium for oxygen and may help decrease the chest pain.

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement first? Select All that Apply

• Administer morphine sulfate Intramuscularly

• Administer an aspirin orally
• Apply oxygen via nasal cannula
• Place the client in a supine position
• Administer nitroglycerin subcutaneously - ANSWER 2. Aspirin is an antiplatelet

medication and should be administered orally.

• Oxygen will help decrease myocardial ischeima, thereby decreasing pain

The client who has had a myocardial infarction is admitted to the telementry unit from intensive care. Which referral would be most appropriate for the client?

• Social worker
• Physical therapy
• Cardiac rehabilitation
• Occupation therapy - ANSWER 3. Cardiac rehabilitation is the most appropriate

referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive exercises, diet teaching, and classes on modifying risk factors.

The client is one day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first?

• Medicate the client with intravenous morphine
• Assess the client's chest dressing and vital signs
• Encourage the client to turn from side to side
• Check the client's telemetry monitor - ANSWER 2. The nurse must always assess the

client to determine if the chest pain that is occurring is expected post-operatively or if it is a complication of surgery.

The client diagnosed with a myocardial infarction is six hours post-right femoral percutanous transluminal coronary angioplasty (PTCA), also known as balloon surgery.

Which assessment data would require immediate intervention by the nurse?

• The client is keeping the affected extremity straight
• The pressure dressing to the right femoral area is intact
• The client is complaining of numbness in the right foot
• The client's right pedal pulse is +3 and bounding - ANSWER 3. Any neurovascular

assessment data that is abnormal requires intervention by the nurse; numbness may indicate decreased blood flow to the right foot

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?

• Notify the health-care provider immediately
• Elevate the head of the client's bed
• Document this as a normal and expected finding
• Administer morphine intravenously - ANSWER 1. An S3 indicates left ventricular failure

and should be reported to the healthcare provider. It is a potentially life threatening complication of a myocardial infarction

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication?

• The client's apical pulse is 64
• The client's calcium level is elevated
• The client's telemetry shows occasional PVCs
• The client's blood pressure is 90/62 - ANSWER 4. The client's blood pressure is low, and

a calcium channel blocker could cause the blood pressure to bottom out.

The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive

personnel is encouraging the client to move the legs. Which action should the nurse implement?

• Instruct the UAP to stop encouraging leg movements
• Report this behavior to the charge nurse as soon as possible
• Praise the UAP for encouraging the client to move legs
• Take no action concerning the UAP's behavior - ANSWER 3. The nurse should praise

and encourage UAPs to participate in the client's care. Clients on bedrest are at risk for developing deep vein thrombosis, and moving the legs will prevent this from occurring.

The client diagnosed with a myocardial infarction asks the nurse, "why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response?

• "Your heart is damaged and needs about 4 to 6 weeks to heal"
• "There is necrotic myocardial tissue that puts you at risk for dysrhythmias"
• "Your doctor has ordered bedrest. Therefore, you must stay in bed."
• "Just because your chest doesn't hurt anymore doesn't mean you are out of danger" -

ANSWER 1. The heart tissue is dead, stress or activity may cause heart failure, and it does take about 6-8 weeks for scar tissue to form

The client has just returned from a cardiac catherization. Which assessment data would warrant immediate intervention from the nurse?

• The client's BP is 110/70 and pulse is 90
• The client's groin dressing is dry and intact
• The client refuses to keep the leg straight
• The client denies any numbness and tingling - ANSWER 3. The client bends the legs, it

could cause insertion site bleeding. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.