A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes that the client's 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?

Allow the client to rest quietly.

Document the findings in the chart.

Assess the client for bleeding.

Medicate the client for pain.

Answer and Explanation

The Correct Answer is C

A. Allow the client to rest quietly: While rest is generally beneficial, the combination of tachycardia and hypotension suggests possible acute complications such as bleeding or cardiogenic shock. Simply allowing the client to rest does not address the underlying cause and could delay life-saving interventions.

B. Document the findings in the chart: Documentation is important for communication and legal purposes, but it is not an immediate intervention. The nurse must first assess the client for potential causes of hemodynamic instability before charting.

C. Assess the client for bleeding: A drop in blood pressure with a compensatory increase in heart rate may indicate hypovolemia from internal or external bleeding, especially if the client has invasive lines or recent procedures. Prompt assessment and intervention are crucial to prevent shock and organ damage.

D. Medicate the client for pain: Pain management is important, but administering analgesics in the context of hypotension and tachycardia could worsen hemodynamic instability. The priority is identifying and treating the underlying cause before giving medications that may further lower blood pressure.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Up in chair at bedside: Early mobilization after CABG, such as sitting in a chair at the bedside, promotes circulation, prevents venous stasis, reduces the risk of pulmonary complications, and supports overall recovery. At 6 hours post-op and 4 hours post-extubation, this level of activity is safe and appropriate under close monitoring.

B. Remove epicardial pacing wires: Epicardial pacing wires are removed 24–48 hours after surgery, depending on physician orders and patient stability. Removing them only a few hours post-op is unsafe and could lead to arrhythmias or bleeding, this is not appropriate at this stage.

C. Use incentive spirometer: Incentive spirometry is critical to prevent atelectasis and improve lung expansion following cardiac surgery. Encouraging the client to use the device frequently helps restore pulmonary function, especially after recent extubation.

D. Dangle at the bedside: Dangling (sitting at the edge of the bed with feet on the floor) is an early step in mobilization that helps the client regain balance, promote circulation, and reduce orthostatic hypotension before ambulating. It is appropriate at this stage of recovery.

E. Maintain NPO status: At 4 hours post-extubation, clients are generally allowed clear liquids if there is no nausea, swallowing difficulty, or risk of aspiration. Continuing NPO status unnecessarily could delay recovery and nutrition.

F. Ambulate to bathroom: Ambulation to the bathroom is typically not safe so soon after extubation and major cardiac surgery due to risk of hypotension, dizziness, or sternal instability. Mobility should begin with bedside sitting and dangling before progressing to walking.

A. Pericardial friction rub. B. Mitral murmur. C. Pleural friction rub. D. S3 or S4.

Correct Answer is A

Explanation

A. Pericardial friction rub: Pericarditis is inflammation of the pericardial sac. The classic auscultatory finding is a high-pitched, scratchy pericardial friction rub heard best at the left lower sternal border. It is caused by the inflamed pericardial layers rubbing against each other and is a hallmark sign of pericarditis.

B. Mitral murmur: A mitral murmur is associated with mitral valve disorders such as mitral stenosis or mitral regurgitation, not inflammation of the pericardium.

C. Pleural friction rub: A pleural friction rub is heard with pleuritis and is related to lung and pleural inflammation. It is respiratory in origin and changes with breathing, unlike a pericardial friction rub.

D. S3 or S4: An S3 is commonly associated with heart failure, and an S4 is often linked to decreased ventricular compliance, such as in hypertension. These are not characteristic findings of acute pericarditis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes that the client's 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is 6 hours post operative, and 4 hours post extubation following coronary artery bypass grafting (CABG) surgery. What nursing interventions are appropriate at this time to include in the plan of care? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse is caring for a client with pericarditis. What heart sounds does the nurse expect to hear during the physical assessment?

Correct Answer is A

Explanation

A nurse is caring for a client with cardiomyopathy and is receiving a dobutamine drip. Which assessment finding indicates that the medication is effectively working?

A nurse prepares a client for an emergent aortic aneurysm open repair. The client states, "I am afraid I might die." What is the nurse's best response?

A client is admitted with infective endocarditis. Which findings during the nursing assessment support this diagnosis? Select all that apply.

Which client has the least risk for developing endocarditis?

The nurse is assessing a client who received a heart transplant 6 months ago for cardiomyopathy. What assessment finding would lead the nurse to suspect the transplant is being rejected?

A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM). What order does the nurse anticipate providing?

Which explanation would the nurse give to the spouse of a client who had coronary artery bypass graft (CABG) surgery when asked why there is a dressing on the client's left leg?

A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed?