Ichs Ms Ll Study Guide

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Sample questions from Ichs Ms Ll Study Guide

This material has 24 questions with answers and rationales. Here are the first 5.

1. 1.A client reports new chest pressure and diaphoresis. Oxygen saturation is 97% on room air, blood pressure is 138/82 mm Hg, and breathing is unlabored. Which action should the nurse prioritize?

   • A.Ask the client to walk to determine whether the pain worsens
   • B.Apply oxygen at 6 L/min regardless of the saturation
   • C.Wait for the first troponin result before notifying the provider
   • D.Obtain a 12-lead ECG promptly and initiate the chest pain pathway

   Rationale: B is correct because suspected acute coronary syndrome requires prompt ECG evaluation and time-sensitive care. A is incorrect because routine oxygen is not indicated in this normoxic, non-distressed client. C delays evaluation and an initial troponin can be normal early in infarction. D increases myocardial demand and is unsafe during possible acute ischemia.

2. 2.A client with chest discomfort has a prescription for sublingual nitroglycerin. Which statement requires the nurse to withhold the medication and clarify the plan?

   • A."I took acetaminophen this morning."
   • B."I took tadalafil yesterday evening."
   • C."I have seasonal allergies."
   • D."My usual resting pulse is 76 beats per minute."

   Rationale: A is correct because tadalafil within the preceding 48 hours is generally a contraindication to nitrate administration due to profound hypotension risk. B does not describe a typical nitrate contraindication. C is unrelated unless a specific drug allergy is present. D describes a normal pulse and does not justify withholding nitroglycerin.

3. 3.A client with heart failure suddenly develops severe dyspnea, crackles, and pink frothy sputum. Which action should the nurse take first while calling for urgent assistance?

   • A.Begin discharge teaching about sodium restriction
   • B.Place the client flat with the legs elevated
   • C.Assist the client upright and support oxygenation
   • D.Encourage a large glass of water

   Rationale: C is correct because the findings suggest acute pulmonary edema, requiring immediate support of breathing and urgent treatment. A can worsen fluid overload. B can worsen respiratory distress and pulmonary congestion. D is important after stabilization but does not address the immediate threat.

4. 4.A postoperative client develops sudden dyspnea, pleuritic chest pain, tachycardia, and an oxygen saturation of 86%. Which complication should the nurse suspect first?

   • A.Pulmonary embolism
   • B.Uncomplicated incisional pain
   • C.Chronic stable anemia
   • D.Expected effects of bed rest

   Answer and rationale are in the full material.

5. 5.A client with chest trauma becomes hypotensive and severely dyspneic. Breath sounds are nearly absent on the right. What is the nurse's priority?

   • A.Arrange routine imaging before contacting the emergency team
   • B.Clamp any existing chest tube for 30 minutes
   • C.Encourage oral fluids to improve blood pressure
   • D.Activate emergency assistance and prepare for immediate decompression

   Answer and rationale are in the full material.