Adult Health Nursing Flashcards

A patient with suspected myocardial infarction presents with chest pain. Which ECG finding is most indicative of STEMI?

Answer: ST-segment elevation in two or more contiguous leads

STEMI (ST-elevation MI) is diagnosed when ST elevation ≥1 mm is present in two or more contiguous leads (or ≥2 mm in V1–V3). This indicates complete coronary occlusion requiring immediate reperfusion therapy.

Which medication should be withheld if a patient's apical pulse is below 60 beats per minute?

Answer: Digoxin

Digoxin slows AV conduction and is held if the apical pulse is <60 bpm (in adults) because the drug could cause dangerous bradycardia. Always take a full apical pulse for one full minute before administering digoxin.

A patient with COPD has a PaO2 of 55 mmHg and PaCO2 of 58 mmHg. What oxygen delivery device should the nurse use?

Answer: Venturi mask at 24–28% FiO2

COPD patients may rely on hypoxic drive for respiration. Controlled low-flow oxygen via Venturi mask (24–28%) raises PaO2 to a safe level (55–65 mmHg) without eliminating the hypoxic drive. High-flow oxygen can cause CO2 retention.

Which assessment finding is an early sign of hypovolemic shock?

Answer: Anxiety and restlessness with tachycardia

In early (compensated) hypovolemic shock, the body maintains blood pressure through sympathetic compensation, but early signs include anxiety, restlessness, and tachycardia. Hypotension is a late, decompensated sign indicating severe blood loss.

A patient is admitted with diabetic ketoacidosis (DKA). Which laboratory finding is most consistent with this diagnosis?

Answer: Blood glucose >250 mg/dL, pH <7.3, bicarbonate <15 mEq/L, positive ketones

DKA is characterized by hyperglycemia (>250 mg/dL), metabolic acidosis (pH <7.3), low bicarbonate (<15 mEq/L), and elevated ketones. This triad results from insulin deficiency causing fat breakdown and ketone production.

Which intervention is priority for a patient in acute pulmonary edema?

Answer: Sit upright, apply high-flow oxygen, and administer IV furosemide as ordered

Acute pulmonary edema is a medical emergency. Sitting the patient upright reduces venous return and lung congestion. High-flow oxygen corrects hypoxemia. IV furosemide rapidly reduces preload by promoting diuresis. Oral medications act too slowly.