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WorksheetsCardiac Prioritization
Total questions: 10
Worksheet time: 10mins
A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What is the highest priority for nursing management of this client at this time?
Monitor daily weights and urine output.
Permit unrestricted visitation by family and friends
Provide client education on medications and diet.
Administer morphine to reduce myocardial demand
A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating nitroglycerin drip?
Serum potassium is 3.5 mEq/L.
Blood pressure is 88/46.
ST elevation is present on the electrocardiogram.
Heart rate is 61.
The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first:
Assess for changes in vital signs.
Draw an arterial blood gas
Evaluate heart sounds with the client learning forward.
Obtain a 12-lead electrocardiogram
The nurse has completed an assessment on a client with a decreased cardiac output. Which finding should receive the highest priority?
BP 110/62, atrial fibrillation with HR 82 bibasilar crackles.
Confusion, urine output 15mL over the last 2 hours, orthopnea.
SpO2 92 on 2L nasal cannula, respirations 20, 1+ pitting edema of lower extremities.
Weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise.
The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first:
Administer atropine 0.5mg IV push.
Auscultate for abnormal heart sounds.
Prepare for transcutaneous pacing.
Take the client's blood pressure.
A 60 year-old comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Admission prescriptions include oxygen by nasal cannula at 4L/min, complete blood count(CBC), a chest radiograph, a 12-lead electrocardiogram (ECG), and 2mg of morphine sulfate given IV. The nurse should first:
Administer the morphine.
Obtain a 12-lead ECG.
Obtain the blood work.
Prescribe the chest radiograph.
The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the patient has experienced a single PVC on the cardiac monitor. The nurse should:
Notify the health care provider
Call the rapid response team
Assess the client for changes in the rhythm
Administer lidocaine as prescribed
The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which of the following changes on the client's chart to the physician? (Compare data from 1300 to data obtained at 1500)
Urine Output (1300: 90mL/ hr; 1500: 20mL/hr).
Heart Rate (1300: 70/ 1500: 75).
Blood Pressure (1300: 110/70; 1500: 100/65).
Respiratory Rate (1300: 20; 1500: 26).
The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. The nurse should do the following in which order from first to last?
1: Obtain a history of which drugs the client has used recently.
2: Administer the prescribed dose of morphine.
3: Position electrodes on the chest.
4: Take vital signs.
1, 4, 2, 3
4, 2, 3, 1
3, 4, 2, 1
2, 4, 1, 3
While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) and oxygen at 2L/min. The nurse's first course of action should be
Increase the IV infusion rate.
Notify the physician promptly.
Increase the oxygen concentration.
Administer a prescribed analgesic.
