Perfusion (MI) NCLEX Questions - all

Perfusion (MI) NCLEX Questions - all Leave the first rating Students also studied Terms in this set (20) Science MedicineNursing Save STAT 330 - Chapter 9 33 terms dylmann15Preview NCLEX 127 terms ssutherland11Preview Vocab Quiz 1 15 terms kaylabayazitoglu Preview u.s stat 50 terms niki Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction?

• 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
• 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
• 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
• 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
• 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 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
• 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
• 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
• 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
• 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"

• 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 Which preprocedure information should be taught to the female client having an exercise stress test in the morning?

• Wear open-toed shoes to the stress test
• Inform the client not to wear a bra
• Do not eat anything for 4 hours
• Take the beta blocker one hour before the test
• NPO decreases the chance of aspiration in case of emergency. In addition, if

the client has just had a meal, the blood supply will be shunted to the stomach for digestion and away from the heart, perhaps leading to an inaccurate test result.The client comes into the emergency department saying, "I am having a heart attack" Which question is most pertinent when assessing the client?

• "Can you describe the chest pain"
• "What were you doing when the pain started"
• "Did you have a high-fat meal today"
• "Does the pain get worse when you lie down"
• The chest pain for MI is usually described as an elephant sitting on the chest or a

belt squeezing the substernal midchest, often radiating to the jaw or left arm.The client is admitted to the emergency department, and the nurse suspects a cardiac problem. Which assessment interventions should the nurse implement? Select All that Apply

• Obtain a midstream urine specimen
• Attach telemetry monitor to the client
• Start a saline lock in the right arm
• Draw a baseline metabolic panel (BMP)
• Request an order for a STAT 12-lead ECG
• Anytime a nurse suspects cardiac problems, the electrical conductivity of the

heart should be assessed.

• Emergency medications for heart problems are primarily administered

intravenously, so starting a saline lock in the right arm is appropriate.

• A 12-lead ECG evaluates the electrical conductivity of the heart from all planes.

The client is 3 hours post myocardial infarction. Which data would warrant immediate intervention by the nurse?

• Bilateral peripheral pulses 2+
• The pulse oximeter reading is 96%
• The urine output is 240 mL in the last 4 hours
• Cool, clammy, diaphoretic skin
• Cold, clammy skin is an indicator of cardiogenic shock, which is a complication

of MI and warrants immediate intervention.

A patient presents to the emergency room complaining of stabbing chest pain. What is the first thing the nurse will do?

• Pain assessment
• Vitals Signs
• Raise head of bed, establish IV access, place 12 lead

EKG

• Give nitroglycerin tabs

A - angina presents similarly to MI but MI will not be relieved by rest (angina is relieved by rest) A patient present to the ED complaining of chest pain.After assessing vitals and pain, the nurse notes RR30 BP 150/90 T 98.7 HR 116 SpO2 90% and the pain is 7/10 with no relief during rest. What is the priority nursing intervention?

• Immediately notify HCP
• Place patient supine
• Place nasal cannula, Raise head of the bead, establish

IV access, obtain 12 lead EKG

• Administer Morphine IV, oxygen via nasal cannula,

Aspirin orally, and nitroglycerin sublingual C What is the primary reason for administering morphine to a client with MI?

• To sedate the client
• to decrease the client's pain

C)decrease the client's anxiety

• decrease oxygen demand on the client's heart

D-Morphine is administered because it decreases myocardial oxygen demand.Which diagnostic tool is used to determine the location of myocardial damage for a patient with a myocardial infarction (MI) ?A)Cardiac catheterization B)Cardiac enzymes C)Echocardiagram D)Electrocardiogram (ECG) D-Elctrocardiogram (ECG) is the quickest, most accurate and most widely used tool to determine the location of a myocardial infarction (MI) What is the first intervention for a client experiencing myocardial infarction (MI) ?A)Administer morphine B)Administer oxygen C)Administer sublingual nitroglycerin D)Obtain an electrocardiogram (ECG)

Answer:

B-Adminstering supplemental oxygen to the client is the number one priority of care.