An adult client with pericarditis is exhibiting muffled heart sounds. The client is diagnosed with cardiac tamponade, and a pericardiocentesis is scheduled. Prior to the procedure, it is most important for the nurse to implement which intervention?

A client who had a percutaneous coronary intervention (PCI) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5 pound weight gain. Which intervention should the nurse implement?

A patient who is admitted with shortness of breath has a tracing with atrial fibrillation at 140 beats/minute of unknown duration. The nurse begins oxygen per nasal cannula and establishes a saline lock. Which should the nurse prepare to implement next?

Based on this strip, which is the interpretation of this rhythm?

Click to highlight the findings that require follow up.

Neurological: Alert and oriented person, place, time, and situation Agitated. Denies headaches.

Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.

Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.

Gastrointestinal: Within normal limits (WNL).

Genitourinary: WNL.

Musculoskeletal M/MIL

Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.

Which nursing problem should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI)?

A client is admitted to the hospital for shortness of breath and chest pain after an episode of syncope. Which laboratory finding is most important for the nurse to report to the healthcare provider (HCP)?

The nurse is assessing a hospitalized client with pulmonary edema who is reporting two pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse observes rapid shallow respirations and use of accessory muscles. Which action should the nurse include in the client's plan of care?

A client is admitted with a confirmed pulmonary embolism (PE). Six hours after heparin IV infusion is initiated, the client's partial thromboplastin time (PTT) is 152 seconds, so the infusion is discontinued. Which intervention is most important for the nurse to implement?

Reference Range:

• Partial Prothrombin Time (PTT) [27 to 41 seconds]

A client was admitted to the cardiac observation unit 2 hours ago reporting chest pain. On admission, the client's electrocardiogram (ECG) displays sinus bradycardia (SB) with ST segment depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest." The ECG now displays Q waves and ST segment elevations in the anterior leads. Which interventions should the nurse perform?

The nurse is reviewing laboratory values of a client who was discharged two weeks ago after experiencing a myocardial infarction. Which finding most requires follow-up with the client?

Reference Range:

• Triglycerides [40 to 160 mg/dL (0.45 to 1.81 mmol/L)]
• Lipase [0 to 160 units/L (0 to 2.67 μkat/L)]
• Low-density lipoproteins (LDL) [less than 130 mg/dL (3.36 mmol/L)]
• High-density lipoproteins (HDL) [greater than 45 mg/dL (greater than 1.16 mmol/L)]