The assessment findings of a patient with myocardial infarction (MI) include jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute. The nurse suspects what complication?

Left-sided HF

Right-sided HF

Chronic heart failure (HF)

Acute decompensated heart failure (ADHF)

Answer and Explanation

The Correct Answer is B

The assessment findings of jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute are consistent with right-sided heart failure (HF). Right-sided HF occurs when the right ventricle of the heart is unable to pump effectively, leading to congestion in the venous circulation. This can result in jugular venous distention (JVD) due to increased pressure in the jugular veins, peripheral edema due to fluid retention, and weight gain due to fluid accumulation.

Option A (Left-sided HF) may also present with similar symptoms like jugular venous distention, weight gain, and peripheral edema. However, in left-sided HF, there would typically be signs of pulmonary congestion, such as crackles in the lungs and shortness of breath.

Option C (Chronic heart failure) is a general term used for heart failure that has been present for an extended period, and it does not specify whether it is left-sided or right-sided heart failure.

Option D (Acute decompensated heart failure - ADHF) is a form of heart failure that presents with severe symptoms and requires urgent treatment. It is more of a clinical classification rather than a specific complication related to the symptoms mentioned in the scenario.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Atropine is an anticholinergic medication that acts by blocking the effects of the parasympathetic nervous system on the heart, leading to an increase in heart rate (positive chronotropic effect) and conduction velocity (positive dromotropic effect). In patients with symptomatic type 1 second degree atrioventricular (AV) block (also known as Mobitz type 1 or Wenckebach), the electrical impulses between the atria and ventricles are delayed or blocked intermittently, resulting in a progressive lengthening of the PR interval until a ventricular beat is dropped.

When atropine is administered to a patient with symptomatic type 1 AV block, it can counteract the increased vagal tone that contributes to the block and help improve the conduction through the AV node. As a result, the heart rate is expected to increase, which is a positive response to the medication.

The other options listed (B) Decrease in premature ventricular contractions, (C) Increase in strength of peripheral pulses, and (D) Decrease in premature atrial contractions, are not directly related to the effect of atropine on type 1 AV block and are not typical findings associated with atropine administration in this context. The main goal of administering atropine in this situation is to increase the heart rate and improve the AV conduction to alleviate symptoms associated with the AV block.

A. Perform synchronized cardioversion. B. Start cardiopulmonary resuscitation (CPR). C. Apply supplemental O₂ via non-rebreather mask. D. Give atropine per agency dysrhythmia protocol.

Correct Answer is B

Explanation

The patient is apneic (not breathing) and has no palpable pulses, indicating a cardiac arrest or severe cardiovascular compromise. In this situation, the most appropriate action for the nurse to take next is to start cardiopulmonary resuscitation (CPR) immediately.

CPR is a life-saving procedure that combines chest compressions and rescue breaths to circulate oxygenated blood to vital organs when the heart is not effectively pumping. In the case of cardiac arrest, early initiation of CPR is critical to improve the chances of survival and minimize potential brain damage.

The heart monitor shows sinus tachycardia, rate 132, which suggests that the electrical impulses are reaching the heart, but the heart is not effectively pumping blood due to the lack of a palpable pulse. This condition requires immediate intervention with CPR rather than other treatments such as synchronized cardioversion (option A) or administering atropine (option D).

While applying supplemental oxygen via a non-rebreather mask (option C) is generally important in many emergency situations, it is not the immediate priority when a patient is apneic and has no palpable pulses. In such cases, CPR takes precedence to restore circulation and maintain oxygen delivery to the body's vital organs.

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

The assessment findings of a patient with myocardial infarction (MI) include jugular venous distention, weight gain, peripheral edema, and a heart rate of 108/minute. The nurse suspects what complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After the nurse gives IV atropine to a patient with symptomatic type 1. second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective?

Correct Answer is A

Explanation

A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?

Correct Answer is B

Explanation

Which diagnostic test will be most useful to the nurse in determining whether a client admitted with acute shortness of breath has heart failure?

The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

A client recovering from heart surgery develops pericarditis and reports level 6 (0 to 10 scale) chest pain with deep breathing. Which prescribed PRN medication will be the most appropriate for the nurse to give?

A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD). The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.)

Which assessment finding of a patient with chronic kidney disease indicates to the nurse that hemodialysis is having the desired effect?

The nurse is reviewing the laboratory test results for a client who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

Which electrocardiographic (ECG) change by a client with chest pain is most important for the nurse to report rapidly to the health care provider?