The nurse is caring for a client receiving morphine 4 mg IV every 15 minutes for chest pain. Which assessment finding is of most concern to the nurse?
Heart rate 68 beats/min
Respiratory rate 8 breaths/min
✓
Blood pressure 118/68 mm Hg
Oxygen saturation 95% on room air
Correct Answer
Respiratory rate 8 breaths/min
Morphine is a potent opioid agonist and can cause respiratory depression and failure. It is very important to monitor the client frequently (reassess at least every 5–10 minutes) when using morphine to control chest pain.
Question 2
The nurse has administered sublingual nitroglycerin to a client with chest pain. Which assessment finding does the nurse anticipate for this client?
A decrease in oxygen saturation
A decrease in blood pressure
✓
An increase in heart rate
An increase in respiratory rate
Correct Answer
A decrease in blood pressure
Nitroglycerin is a vasodilator, and vasodilation causes the blood pressure to drop.
Question 3
At what rate should the nurse administer adenosine 6 mg IV to a client with supraventricular tachycardia?
Slowly over 1–2 hours
Over 5–10 minutes
Over 1 minute
Over 1–2 seconds
✓
Correct Answer
Over 1–2 seconds
Adenosine has a very short half-life and should be administered as a rapid IV bolus directly into a vein over 1–2 seconds, followed by a rapid saline flush.
Question 4
Which question should the nurse ask a client before administering nitroglycerin for chest pain?
Do you have a history of asthma?
Do you have Wolff–Parkinson–White syndrome?
Do you have lupus erythematosus?
Do you take any medications for erectile dysfunction?
✓
Correct Answer
Do you take any medications for erectile dysfunction?
The nurse should ask whether the client is taking any medications for erectile dysfunction because the use of nitroglycerin is contraindicated in clients who are taking a phosphodiesterase inhibitor such as tadalafil or sildenafil.
Question 5
The nurse in the emergency department is caring for a client who reports chest pain that is relieved at rest. Which diagnosis should the nurse anticipate?
Ventricular dysrhythmia
Unstable angina
Stable angina
✓
Myocardial infarction
Correct Answer
Stable angina
Stable angina occurs during exercise or exertion and improves with rest. Stable angina presents when the heart needs more oxygen but the supply of oxygen is restricted. Once the heart does not need increased oxygen, the angina subsides.
Question 6
The health care provider has ordered diltiazem IV bolus 0.25 mg/kg for a client with atrial fibrillation with rapid ventricular response. The client weighs 176 lb (80 kg). What is the correct dose of diltiazem for the nurse to administer?
20 mg
✓
25 mg
30 mg
15 mg
Correct Answer
20 mg
The ordered dose of diltiazem is 0.25 mg/kg, and so
Question 7
Which therapeutic response would the nurse anticipate when administering epinephrine to a client in anaphylaxis?
Bronchodilation
✓
Hypotension
Bradycardia
Hypokalemia
Correct Answer
Bronchodilation
The therapeutic effects of epinephrine include bronchodilation, increased heart rate, and increased blood pressure.
Question 8
Which adverse effect should the nurse monitor for in the client receiving dopamine by peripheral IV infusion?
Skin sloughing at the IV site
✓
Facial flushing
Electrolyte abnormalities
Dizziness
Correct Answer
Skin sloughing at the IV site
Dopamine causes vasospasm and can lead to necrosis, sloughing, and potentially gangrene if extravasation into the tissue occurs at the IV site.
Question 9
The nurse in the cardiology clinic is caring for a client taking an antidysrhythmic medication for ventricular dysrhythmia who develops a positive antinuclear antibody test. Which antidysrhythmic medication does the nurse anticipate this client is taking?
Diltiazem
Lidocaine
Procainamide
✓
Amiodarone
Correct Answer
Procainamide
Prolonged use of procainamide may lead to a positive antinuclear antibody test; if this occurs, the risk–benefit ratio of procainamide use should be reassessed.
Question 10
What is the preferred route for administering epinephrine to a client with anaphylaxis who is in sinus tachycardia?
Intravenous
Intramuscular
✓
Sublingual
Inhalation
Correct Answer
Intramuscular
Epinephrine is administered intramuscularly for the client in anaphylaxis who does not have ventricular fibrillation, pulseless ventricular tachycardia, asystole, or pulseless electrical activity.