CONCEPT: CARE OF CLIENTS ACROSS LIFESPAN WITH PROBLEMS IN

ACUTE BIOLOGIC CRISIS

Concept Lecturer : Sir Klins B. Oliver, RN,IVTN, CRNS,FN
Concept : Cardiac Failure / Acute Myocardial Infarction / Myocardial Infarction/ BLS ACLS/
ECG Arrhythmias
1. Mang Jose is admitted in the ER with a diagnosis of Acute Myocardial Infarct (AMI). He is attached to a cardiac monitor
and has an IV catheter in place, 1L of PNSS @KVO rate infusing well at right metacarpal vein. His cardiac rhythm has
been showing normal sinus rhythm with occasional PVCs. You, the nurse notes a sudden change in the rhythm to a
very irregular chaotic looking pattern. The client appears to be asleep. The most appropriate action you will be doing
will be?

a. Administer 1mg of Epinephrine via IV push

b. Deliver precodial thump to the patient
c. Check the placement of the electrodes
d. Perform resuscitative measures such as CPR

2. Lola Sarita, 78 years old admitted in the female ward received 0.25mg of Digoxin as treatment for her Congestive
Heart Failure (CHF). Which of these physiologic responses indicates that the drug is taking its desired effect towards
the patient?

a. Decreased cardiac output

b. Increased urine output
c. Decreased urine output
d. Increased heart rate

3. An adult client has a central line place for IV fluids. As you enter the room the IV bottle is empty and the IV line is full
of air and the client is dyspneic. What is your best initial nursing action?

a. Begin CPR and call the code team

b. Follow up another IV Fluid as quickly as possible, then remove the air in the IV line.
c. Clamp the tubing to prevent air embolism and place the patient on his left side with the head down.
d. Notify physician and administer oxygen at 2-3LPM via nasal cannula immediately.

4. Don Pepe is admitted to San Lazatins coronary Care Unit until to rule out Myocardial Infarction. He states that. I am
not sure if it is just angina, and I cannot understand the difference between angina and heart attack pain. You as the
nurse should give the most appropriate response as?

a. Anginal pain produces clenching of fists over the chest while acute MI pain does not.
b. Anginal pain radiates to the left arm while acute MI does not.
c. Anginal pain requires morphine for relief.
d. Anginal pain lasts only for 3-5 minutes.

5. An adult is admitted with an acute exacerbation of congestive heart failure. Vital signs are : T-36.5 P-117, R-34 and
BP-155/100. Ankles are edematous and crackles are auscultated at bases of both lungs, 0.5mg of Digoxin (Lanoxin) IV
and 40mg of Furosemide (Lasix) IV are administered immediately. As the nurse, you will recognize that the desired
therapeutic effect has been reached thru what assessment?

a. The clients pulse rate goes down to 100

b. The client had an increased urine specific gravity
c. The client expectorates frothy sputum
d. The clients lungs are clear to auscultation

6. A client is admitted due to cardiogenic shock. To best evaluate the hearts hemodynamic performance, the nurse shall
anticipate the insertion of a (an)?

a. Schwann-Ganz catheter
b. Central Venous Pressure Line (CVP)
c. Intra-Aortic Balloon Pump (IABP)
d. Foley catheter

7. Greta is a nurse assigned in the ICU, having gained the knowledge on Advance Cardiac Life Support, she knows that
during a cardiac emergency the first nursing intervention and drug she is going to give to the patient is?

a. Push 1mg/kg of Lidocaine via IV

b. Perform CPR at 30:2 ratio and call a code immediately
c. Give/maintain oxygen administration at 2-3 LPM
d. Push 1mg of Epinephrine via IV
8. Nicanor, 45 years old, experienced myocardial infarction yesterday. His cardiac monitor shows 6 to 8 PVCs per
minute and occasional presenting couplets. As the nurse assigned to the said patient, your best action by this time is
to?

a. Administer the ordered PRN dose of Lidocaine 1mg/kg to Nicanor

b. Perform precordial thump
c. Monitor the client for development of ventricular tachycardia
 d. Initiate resuscitative measure immediately and call for a code

9. As a knowledgeable nurse, you know that the assessment hallmark to a patient who presents a Right Ventricular
Failure is?

a. Crackles upon auscultation

b. Pink frothy sputum
c. Paroxysmal nocturnal dyspnea
d. Jugular vein distention

10. As you are about to make your nursing diagnosis, you considered your clients presenting features such as fatigue,
tachycardia, crackles upon auscultation and pink frothy sputum. Which nursing diagnosis is of MOST importance?

a. Impaired Gas Exchange

b. Impaired Skin Integrity
c. Risk for Infection
d. Impaired Bed Mobility

11.