Cardio Exam 3 Practice

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously.

2. Aspirin is an antiplatelet medication and should be administered orally. 3. Oxygen will help decrease myocardial ischemia, thereby decreasing pain.

A nurse is caring for a client who is to receive a unit of packed red blood cells (PRBCs). Which safety measure should the nurse implement when administering the blood transfusion? a. stop the transfusion if a reaction occurs and administer 0.9% NaCl at the IV catheter hub to keep the intravenous site patent

ANS: A

A patient has had an elevated temperature of 100.8 F (38.2 C) for 3 days since experiencing a myocardial infarction. The nurse understands that this fever indicates: a. a normal response to necrotic tissue of infarction

ANS: A

The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which ethnic group would the nurse select as the highest priority for this intervention? A. White male B. Hispanic male C. African American male D. Native American female

A. White male The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or African Americans. African Americans have an earlier age of onset and more severe CAD than whites and more than twice the mortality rate of whites of the same age. Native Americans have increased mortality in less than 35-year-olds and have major modifiable risk factors such as diabetes.

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? 1. Notify the health-care provider immediately. 2. Elevate the head of the client's bed. 3. Document this as a normal and expected finding. 4. Administer morphine intravenously.

ANS: 1 An S3 indicates left ventricular failure and should be reported to the health-care provider. It is a potential life-threatening complication of a myocardial infarction.

Which meal would indicate the client understands the discharge teaching concerning the recommended diet for coronary artery disease? 1. Baked fish, steamed broccoli, and garden salad. 2. Enchilada dinner with fried rice and refried beans. 3. Tuna salad sandwich on white bread and whole milk. 4. Fried chicken, mashed potatoes, and gravy.

ANS: 1 Baked fish, steamed broccoli, and garden salad.1. The recommended diet for CAD is low fat, low cholesterol, and high fiber.The diet described is a diet that is low in fat and cholesterol. 2. This is a diet very high in fat and cholesterol. 3. The word "salad" implies something has been mixed with the tuna, usually mayonnaise, which is high in fat, but even if the test taker did not know this, white bread is low in fiber and whole milk is high in fat.4. Meats should be baked, broiled, grilled—not fried. Gravy is high in fat.

A patient with CHF is being treated with a variety of medications, including Digoxin and Lasix. Which of the following assessment findings would lead the nurse to suspect that the patient is hypokalemic? a. Muscle weakness and leg cramps

ANS: A

The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? 1. Instruct the client to keep a diary of activity,especially when having chest pain. 2. Discuss the need to remove the Holter monitor during a.m. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor.

ANS: 1 The Holter monitor is a 24-hour electrocardiogram,and the client must keep an accurate record of activity so that the health-care provider can compare the ECG recordings with different levels of activity.

The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four(4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bed rest. Therefore,you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."

ANS: 1 The heart tissue is dead, stress or activity may cause heart failure, and it does takeabout six (6) weeks for scar tissue to form.

The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia to the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

ANS: 1 This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain.

A nurse completes assessments at 1 pm on these clients who are admitted with angina and type 1 DM. All of the clients received subcutaneous NovoLog insulin at 0730. In which order (1-4) should the nurse assess the clients? 2. A client who has just vomited for the second time 3. A client with blood glucose level of 300 mg/dL 1. A client who is short of breath and has chest tightness and new onset atrial tachycardia 4. A client with a blood glucose level of 76 mg/dL

ANS: 1, 2, 3, 4

After receiving the shift report for four clients, in which order (1-4) should the nurse assess the clients? 2. A client with a mitral valve replacement 2 days ago, BP 120/68, HR 98, RR 26, T 38.4 C 3. A chest pain client receiving heparin IV and has aPTT due back in 35 minutes 1. A received 2 hours ago from the ICU following CABG and has new onset A. fib 4. End-stage cardiomyopathy client with BP of 80/60 mg Hg, 25 mL/hr urine output, and a "Do not resuscitate" order

ANS: 1, 2, 3, 4

A nurse's five patients have diagnoses of chest pain. In which order (1-5) should the nurse address each lab value? 5. WBCs 12,500 K/uL 2. Cholesterol 475 mg/dL 3. Hgb 8.2 g/dL 1. Troponin T 37 ng/mL (0.0 - 0.4 ng/mL) 4. SCr 2.3 mg/dL

ANS: 1, 2, 3, 4, 5

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct the client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to a counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.

ANS: 1, 2, 4, 5 1. A low-fat, low-cholesterol diet will help decrease the buildup of atherosclerosis in the arteries.2. Walking will help increase collateral circulation. 4. Stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle. 5. Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system.

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.

ANS: 2

The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client's potassium level is 4.5 mEq/L.

ANS: 2 A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates a lower-than-normal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate.

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool, clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.

ANS: 2 Diaphoresis (sweating) is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.

ANS: 2 Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client's potassium level, and if the client is hypokalemic, the nurse should question administering this medication.

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately.

ANS: 2 Stopping the activity decreases the heart's need for oxygen and may help decrease the angina (chest pain).

Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."

ANS: 2 The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat.

The client with coronary artery disease is prescribed transdermal nitroglycerin, a coronary vasodilator. Which behavior indicates the client understands the discharge teaching concerning this medication? 1. The client places the medication under the tongue. 2. The client removes the old patch before placing the new. 3. The client applies the patch to a hairy area. 4. The client changes the patch every 36 hours.

ANS: 2 The client removes the old patch before placing the new. 1. The client does not understand how to apply this medication; it is placed on the skin, not under the tongue. 2. This behavior indicates the client understands the discharge teaching. 3. The patch needs to be in a non hairy place so it makes good contact with the skin. 4. The patch should be changed every 12 or 24 hours but never every two (2) hours. It takes two (2) hours for the patch to warm up and begin delivering the optimum dose of medication.

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor.

ANS: 2 The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery.

The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high Fowler's position. 4. Assess the gag reflex prior to feeding the client.

ANS: 2 The nurse must make sure that blood is circulating to the right leg, so the client should be assessed for pulses, paresthesia,paralysis, coldness, and pallor.

Which client would most likely be misdiagnosed for having a myocardial infarction? 1. A 55-year-old Caucasian male with crushing chest pain and diaphoresis. 2. A 60-year-old Native American male with an elevated troponin level. 3. A 40-year-old Hispanic female with a normal electrocardiogram. 4. An 80-year-old Peruvian female with a normal CK-MB at 12 hours.

ANS: 3 A 40-year-old Hispanic female with a normal electrocardiogram. 1. Crushing pain and sweating are classic signs of an MI and should not be misdiagnosed. 2. An elevated troponin level is a benchmark in diagnosing an MI and should not be misdiagnosed. 3. The clients who are misdiagnosed concerning MIs usually present with atypical symptoms. They tend to be female, be younger than 55 years old, be members of a minority group, and have normal electrocardiograms. 4. CK-MB may not elevate until up to 24 hours after onset of chest pain.

he charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.

ANS: 3 A new graduate should be able to complete a pre procedure checklist and get this client to the catheterization laboratory.

The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty(PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client's right pedal pulse is 3+ and bounding.

ANS: 3 Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood supply to the right foot.

The client has an implantable cardioverter defibrillator (ICD). Which discharge instructions should the nurse teach the client? 1. Do not lift or carry more than 23 kg. 2. Have someone drive the car for the rest of your life. 3. Carry the cell phone on the opposite side of the ICD. 4. Avoid using the microwave oven in the home.

ANS: 3 Carry the cell phone on the opposite side of the ICD. 1. Clients should not lift more than 5 to 10 pounds because it puts a strain on the heart; 23 kg is more than 50 pounds. 2. There may be driving restrictions, but the client should be able to drive independently. 3. Cell phones may interfere with the functioning of the ICD if they are placed too close to it. 4. Microwave ovens should not cause problems with the ICD.

Which preprocedure information should be taught to the female client having an exercise stress test in the morning? 1. Wear open-toed shoes to the stress test. 2. Inform the client not to wear a bra. 3. Do not eat anything for four (4) hours. 4. Take the beta blocker one (1) hour before the test.

ANS: 3 Do not eat anything for four (4) hours. 1. The client should wear firm-fitting, solid athletic shoes. 2. The client should wear a bra to provide adequate support during the exercise. 3. NPO decreases the chance of aspiration in case of emergency. In addition, if the client has just had a meal, the blood supply will be shunted to the stomach for digestion and away from the heart, perhaps leading to an inaccurate test result. 4. A beta blocker is not taken prior to the stress test because it will decrease the pulse rate and blood pressure by direct parasympathetic stimulation to the heart.

The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client's groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling.

ANS: 3 If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays (CXRs)?" 3. "Are you sexually active?" 4. "Have you had any weight change?"

ANS: 3 Sexual activity is a risk factor for angina resulting from coronary artery disease.The client's being elderly should not affect the nurse's assessment of the client's concerns about sexual activity.

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram (ECG). 3. Have the client sit down immediately. 4. Assess the client's vital signs.

ANS: 3 Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.

The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the UAP to stop encouraging the leg movements. 2. Report this behavior to the charge nurse as soon as possible. 3. Praise the UAP for encouraging the client to move the legs. 4. Take no action concerning the UAP's behavior.

ANS: 3 The nurse should praise and encourage UAPs to participate in the client's care.Clients on bedrest are at risk for deep vein thrombosis, and moving the legs will help prevent this from occurring.

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells (WBCs).

ANS: 3 Troponin is the enzyme that elevates within 1 to 2 hours.

The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40˚F. 4. Wear open-toed shoes when ambulating.

ANS: 3 When it is cold outside, vasoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside.

The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapy.

ANS: 3 Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive exercise,diet teaching, and classes on modifying risk factors.

The nurse is preparing to administer digoxin 0.25 mg IVP to a client in severe congestive heart failure who is receiving D5W/ 0.9 NaCl at 25 mL/hr. Rank in order of importance. 1. Administer the medication over 5 minutes 2. Dilute the medication with normal saline 3. Draw up the medication in a tuberculin syringe 4. Check the client's identification band 5. Clamp the primary tubing distal to the port

ANS: 3, 2, 4, 5, 1

Which population is at a higher risk for dying from a myocardial infarction? 1. Caucasian males. 2. Hispanic females. 3. Asian males. 4. African American females.

ANS: 4 African American females 1. Caucasian males have a high rate of coronary artery disease, but they don't delay seeking health care as long as some other ethnic groups. The average delay time is five (5) hours. 2. Hispanic females are at higher risk for diabetes than for dying from a myocardial infarction. 3. Asian males have fewer cardiovascular events, which is attributed to their diet,which is high in fiber and omega-3 fatty acids. 4. African American females are 35% more likely to die from coronary artery disease than any other population. This Population has significantly higher rates of hypertension and it occurs at younger age. The higher risk of death from an MI is also attributed to a delay in seeking emergency care—an average of 11 hours.

The telemetry nurse notes a peaked T wave for the client diagnosed with congestive heart failure. Which laboratory data should the nurse assess? 1. CK-MB. 2. Troponin. 3. BNP. 4. Potassium.

ANS: 4 Potassium. 1. CK-MB is assessed to determine if the client has had a myocardial infarction. The electrical activity of the heart will not be affected by elevation of this enzyme. 2. Troponin is assessed to determine if the client has had a myocardial infarction. The electrical activity of the heart will not be affected by elevation of this enzyme. 3. Beta-type natriuretic peptide (BNP) is elevated in clients with congestive heart failure, but it does not affect the electrical activity of the heart. 4. Hyperkalemia will cause a peaked T wave; therefore, the nurse should check these laboratory data.

The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."

ANS: 4 The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency department or call 911.

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client's apical pulse is 64. 2. The client's calcium level is elevated. 3. The client's telemetry shows occasional PVCs. 4. The client's blood pressure is 90/58.

ANS: 4 The client's blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out.

The unlicensed assistive personnel (UAP) tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first? 1. Tell the UAP to go take the client's vital signs. 2. Ask the UAP to have the telemetry nurse read the strip. 3. Notify the client's health-care provider. 4. Go to the room and assess the client's chest pain.

ANS: 4. Go to the room and assess the client's chest pain. 1. The client with CAD who is having chestpain is unstable and requires further judgment to determine appropriate actions to take, and the UAP does not have that knowledge. 2. The UAP could go ask the telemetry nurse, but this is not the first action. 3. The client's HCP may need to be notified,but this is not the first intervention. 4. Assessment is the first step in the nursing process and should be implemented first; chest pain is priority.

3 months following a hospital discharge for an MI, a patient's doctor recommends that the patient increase his exercise. Which of the following sports would probably be contraindicated? a. Cross country skiing

ANS: A

A 62-year-old woman weighs 92 kg and has a history of daily alcohol intake, smoking, HTN, high Na+ intake, and sedentary lifestyle. The nurse identifies the risk factors most highly related to atherosclerosis in this patient as a. cigarette smoking and HTN

ANS: A

A diagnosis of acute coronary syndrome is the admission diagnosis for a patient transferred from CCU. The nurse knows that this diagnosis indicates that the patient has experienced a a. unstable angina or a myocardial infarction b. resuscitation following sudden cardiac death c. an onset of any severe cardiac-related chest pain d. a myocardial infarction with ST elevation

ANS: A

A patient with a history of chronic CHF is hospitalized with severe dyspnea and a dry, hacking cough. She has pitting edema on both ankles and her vital signs are BP 170/100, pulse 92, respirations 28. The nurse recognizes that the patient's symptoms indicate a. There is impaired emptying of both the right and left ventricles with low forward blood flow

ANS: A

A patient with chronic congestive heart failure tells the nurse at the clinic that he has gained 5 pounds in the last 3 days, even though he has continued to follow a low-sodium diet. The nurse recognizes the patient a. Should be evaluated for other symptoms that would indicate an exacerbation of congestive heart failure

ANS: A

A patient's wife calls the clinic and informs the nurse her husband is having angina but refuses to go to the hospital. What should the nurse tell the caller to do? a. Tell the wife to have her husband chew an aspirin b. Ask the wife what the husband had to eat recently c. Instruct the wife to call her primary care provider immediately d. Request that the husband talk to his neighbor who is a nurse

ANS: A

Based on these lab values, which value indicates that therapy with Vitamin B12 for anemia has been effective? a. reticulocytes 1%

ANS: A

Classic signs of cardiogenic shock include all of the following except a. Bradycardia

ANS: A

For the client diagnosed with heart failure, what is the primary nursing diagnosis? a. decreased cardiac output b. increased cardiac output c. fluid volume deficit d. knowledge deficit

ANS: A

In developing a teaching plan for the patient with angina the nurse recognizes that teaching about the first line of drug therapy for angina will include instructions about a. using one aspirin a day

ANS: A

Nitroglycerin is indicated as one of the first medications given for chest pain in angina because it a. decreases workload of the heart through decreasing preload and dilates the coronary arteries b. decreases workload of the heart through increasing preload and dilates the coronary arteries c. decreases workload of the heart through decreasing afterload and constricting the coronary arteries d. decreases workload of the heart through decreasing heart rate and decreasing cardiac contractility

ANS: A

Sublingual nitroglycerin helps relieve angina pain by a. increasing oxygen supply to the heart

ANS: A

The CK-MB level is markedly elevated in a patient with chest pain 12 hours after admission. The nurse interprets this finding as evidence of a. cellular necrosis of myocardial tissue

ANS: A

The cardiac monitor shows the rhythm displayed. (Ventricular fibrillation) After calling for assistance, which action should the nurse take next? a. initiate resuscitation interventions b. ask the client's family if they want to make the client a DNR c. perform a pericardial rub d. call the HCP first

ANS: A

The nurse administers IV nitroglycerin to a patient with a myocardial infarction. In evaluating the effect of this intervention, the nurse recognizes that an expected outcome of the administration of the drug is: a. relief of pain b. decreased heart rate c. increased cardiac output d. control of cardiac arrhythmias

ANS: A

The nurse closely monitors the fluid balance of a patient in congestive heart failure, with the knowledge that additional sodium and water retention occur in an already congested vascular system as a result of a. decreased glomerular blood flow in the kidney

ANS: A

The nurse develops a care plan for a patient with a diagnosis of acute myocardial infarction. Of the following, the priority nursing diagnosis in the acute phase would be a. anxiety

ANS: A

Three days after a myocardial infarction the patient develops chest pain that radiates to the back and left arm and is relieved by sitting in a forward position. On auscultation of a patient's chest the nurse would expect to hear a. pericardial friction rub

ANS: A

Treatment of polycythemia vera may include a. phlebotomy b. rotating tourniquets c. potent diuretic therapy d. diet high in iron

ANS: A

What is the primary reason that oxygen is administered to a patient with myocardial infarction? a. To decrease the conversion of ischemic tissue to necrotic tissue

ANS: A

When assessing the patient in shock, the nurse understands that the hemodynamics of shock include a. wide variations in cardiac output and systemic vascular resistance in septic shock

ANS: A

When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse a. urine output 15 mL for 2 hours

ANS: A

When caring for a patient with acute myocardial infarction, the nurse monitors the patient closely, knowing that the most common complication of myocardial infarction is: a. dysrhythmias

ANS: A

When obtaining a health history for a patient with newly diagnosed coronary artery disease, the nurse recognizes that a modifiable risk factor for coronary artery disease is present in the patient's history of a. Hypertension

ANS: A

When palpating a 78-year-old patient's chest during physical assessment, the nurse palpates the PMI at the 6th intercostal space and lateral to left midclavicular line. Which of the following would demonstrate the significance of this finding? a. The patient may have left ventricular enlargement and more data is needed.

ANS: A

While caring for a patient with angina, the nurse plans interventions that decrease myocardial oxygen demand and promote coronary blood flow. Appropriate interventions are those that primarily prevent a. An increase in heart rate

ANS: A

When assessing a patient in shock, the nurse notes a drop in the systolic BP from 92 mm Hg to 76 mm Hg when the head of the patient's bed is elevated to 75 degrees. This finding indicates a need for a. additional fluid replacement b. antibiotic administration c. infusion of a sympathomimetic drug d. administration of increased oxygen

ANS: A a. additional fluid replacement

A patient is taking hydrochlorothiazide (HCTZ), a potassium-wasting diuretic for treatment of HF. The nurse will teach the patient to report symptoms of adverse effects such as a. generalized weakness b. facial muscle spasms c. frequent loose stools d. personality changes

ANS: A a. generalized weakness

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? a. O2 saturation of 88% b. Weight gain of 1 kg (2.2 lb) c. Heart rate of 106 beats/min d. Urine output of 50 mL over 2 hours

ANS: A A decrease in O2 saturation to less than 92% indicates hypoxemia, and the nurse should start supplemental O2 immediately. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output may also indicate worsening heart failure and require nursing actions, but the low O2 saturation rate requires the most immediate nursing action.

Which patient is most likely to develop anemia related to an increased destruction of red blood cells? a. A 23-yr-old black man who has sickle cell disease b. A 59-yr-old man whose alcohol use caused folic acid deficiency c. A 13-yr-old child with impaired growth and development due to thalassemia d. A 50-yr-old woman with a history of "heavy periods" accompanied by anemia

ANS: A A result of a sickling episode in sickle cell anemia involves increased hemolysis of the sickled cells. Thalassemias and folic acid deficiencies cause a decrease in erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.

A patient will receive a hematopoietic stem cell transplant (HSCT). What is the nurse's priority after the patient receives combination chemotherapy before the transplant? a. Prevent patient infection. b. Avoid abnormal bleeding. c. Give pneumococcal vaccine. d. Provide companionship while isolated.

ANS: A After combination chemotherapy for HSCT, the patient's bone marrow is destroyed in preparation to receive the bone marrow graft. Thus, the patient is immunosuppressed and is at risk for a life-threatening infection. The priority is preventing infection. Bleeding is not usually a problem. Giving the pneumococcal vaccine at this time should not be done; it should have been done previously. Providing companionship is not the primary role of the nurse, although the patient will need support during the time of isolation.

A patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). Which patient assessment would determine the effectiveness of the medication? A. Presence of chest pain B. Blood in the urine or stool C. Tachycardia with hypotension D. Decreased level of consciousness

ANS: A Alteplase is a fibrinolytic agent that is administered to patients who have had a STEMI. If the medication is effective, the patient's chest pain will resolve because the medication dissolves the thrombus in the coronary artery and results in reperfusion of the myocardium. Bleeding is a major complication of fibrinolytic therapy. Signs of major bleeding include decreased level of consciousness, blood in the urine or stool, and increased heart rate with decreased blood pressure.

When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? A. Attach the heart monitor. B. Obtain the blood pressure. C. Assess the peripheral pulses. D. Auscultate the breath sounds.

ANS: A Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a heart monitor. The other actions are also important and should be accomplished as quickly as possible.

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Skin cool and clammy b. Heart rate of 118 beats/min c. Blood pressure of 92/56 mm Hg d. O2 saturation of 93% on room air

ANS: A Because patients in the early stage of septic shock have warm and dry skin, the patient's cool and clammy skin indicates that shock is progressing. The other information will also be reported but does not indicate deterioration of the patient's status

A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to the nurse. Which information is most important to communicate to the health care provider? A. Generalized muscle aches and pains B. Dizziness with rapid position changes C. Nausea when taking the drugs before meals D. Flushing and pruritus after taking the drugs

ANS: A Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed.

An older adult patient with chronic heart failure (HF) and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed to continue at home. What is the best response by the nurse? a. "The medication prevents blood clots from forming in your heart." b. "The medication dissolves clots that develop in your coronary arteries." c. "The medication reduces clotting by decreasing serum potassium levels." d. "The medication increases your heart rate so that clots do not form in your heart."

ANS: A Chronic HF causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin K-dependent clotting factors.

A patient admitted to the emergency department 24 hours ago with reports of chest pain was diagnosed with a ST-segment-elevation myocardial infarction (STEMI). What complication of myocardial infarction should the nurse anticipate? A. Dysrhythmias B. Unstable angina C. Cardiac tamponade D. Sudden cardiac death

ANS: A Dysrhythmias are present in 80% to 90% of patients after myocardial infarction (MI). Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

Which assessment finding should be considered when caring for a woman with suspected coronary artery disease? A. Fatigue may be the first symptom. B. Classic signs and symptoms are expected. C. Increased risk is present before menopause. D. Women are more likely to develop collateral circulation.

ANS: A Fatigue, rather than pain or shortness of breath, may be the first symptom of impaired cardiac circulation. Women may not exhibit the classic signs and symptoms of ischemia such as chest pain which radiates down the left arm. Neck, throat, or back pain may be symptoms experienced by women. Risk for coronary artery disease increases four times after menopause. Men are more likely to develop collateral circulation.

A 78-kg patient in septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. After initial fluid volume resuscitation, the patient's urine output has been 30 mL/hr for the past 3 hours. Which order by the health care provider should the nurse question? a. Administer furosemide (Lasix) 40 mg IV. b. Increase normal saline infusion to 250 mL/hr. c. Give hydrocortisone (Solu-Cortef) 100 mg IV. d. Use norepinephrine to keep systolic BP above 90 mm Hg.

ANS: A Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. Patients in septic shock need large amounts of fluid replacement. If the patient is still hypotensive after initial volume resuscitation with minimally 30 mL/kg, vasopressors such as norepinephrine may be added. IV corticosteroids may be considered for patients in septic shock who cannot maintain an adequate BP with vasopressor therapy despite fluid resuscitation.

A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)? A. Reinforcement of teaching about the prescribed medications B. Evaluation of the patient's response to walking in the hallway C. Completion of the referral form for a home health nurse follow-up D. Education of the patient about the pathophysiology of heart disease

ANS: A LPN/VN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient's response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning and referral are skills that require RN education and scope of practice.

At a clinic visit, the nurse provides dietary teaching for a patient recently hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is successful if the patient makes which statement? a. "I will limit the amount of milk and cheese in my diet." b. "I can add salt when cooking foods but not at the table." c. "I will take an extra diuretic pill when I eat a lot of salt." d. "I can have unlimited amounts of foods labeled as reduced sodium."

ANS: A Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet. Salt should not be added during food preparation or at the table. Diuretics should be taken as prescribed (usually daily) and not based on sodium intake. Foods labeled as reduced sodium contain at least 25% less sodium than regular.

A patient in the intensive care unit who has acute decompensated heart failure (ADHF) reports severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been prescribed for the patient. Which action should the nurse take first? a. Give PRN IV morphine sulfate 4 mg. b. Give PRN IV diazepam (Valium) 2.5 mg. c. Increase nitroglycerin infusion by 5 mcg/min. d. Increase dopamine infusion by 2 mcg/kg/min.

ANS: A Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.

The patient is admitted with hypercalcemia, polyuria, and pain in the pelvis, spine, and ribs with movement. Which hematologic problem would most likely cause these manifestations? a. Multiple myeloma b. Thrombocytopenia c. Megaloblastic anemia d. Myelodysplastic syndrome

ANS: A Multiple myeloma typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems. Serum hyperviscosity syndrome can cause renal, cerebral, or pulmonary damage. Thrombocytopenia, megaloblastic anemia, and myelodysplastic syndrome are not characterized by these manifestations.

A client presents to the emergency department with complaints of substernal chest pain. Eight hours later, it is noted upon laboratory assessment that myoglobin levels have not risen. What conclusion can be drawn from this information? a. The client has not experienced a myocardial infarction. b. The client is experiencing an evolving myocardial infarction. c. The client most likely had a myocardial infarction several days ago. d. The client has experienced a myocardial infarction within the last 24 hours.

ANS: A a. The client has not experienced a myocardial infarction.

Which action should the nurse include in the plan of care for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? a. Monitor blood pressure frequently. b. Encourage patient to ambulate in room. c. Teach patient to drink at least 3 liters of fluid daily. d. Titrate nesiritide dose down slowly before stopping.

ANS: A Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Because the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration. Excessive hydration could exacerbate ADHF.

Which patient is at greatest risk for sudden cardiac death (SCD)? A. A 52-yr-old black man with left ventricular failure B. A 62-yr-old obese man with diabetes and high cholesterol C. A 42-yr-old white woman with hypertension and dyslipidemia D. A 72-yr-old Native American woman with a family history of heart disease

ANS: A Patients with left ventricular dysfunction (ejection fraction less than 30%) and ventricular dysrhythmias after myocardial infarction are at greatest risk for SCD. Other risk factors for SCD include: (1) male gender (especially blacks), (2) family history of premature atherosclerosis, (3) tobacco use, (4) diabetes, (5) high cholesterol levels, (6) hypertension, and (7) cardiomyopathy.

When caring for a patient in acute septic shock, what should the nurse anticipate? a. Infusing large amounts of IV fluids b. Administering osmotic and/or loop diuretics c. Administering IV diphenhydramine (Benadryl) d. Assisting with insertion of a ventricular assist device (VAD)

ANS: A Septic shock is characterized by a decreased circulating blood volume. Volume expansion with the administration of IV fluids is the cornerstone of therapy. Administering diuretics is inappropriate. VADs are useful for cardiogenic shock, not septic shock. Diphenhydramine may be used for anaphylactic shock but would not be helpful with septic shock.

When planning emergent care for a patient with a suspected myocardial infarction (MI), what should the nurse anticipate administering? A. Oxygen, nitroglycerin, aspirin, and morphine B. Aspirin, nitroprusside, dopamine, and oxygen C. Oxygen, furosemide (Lasix), nitroglycerin, and meperidine D. Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

ANS: A The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient's treatment.

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is high, and cardiac output is low. Which treatment would the nurse expect to be prescribed? a. Furosemide b. Hydrocortisone c. Epinephrine drip d. 5% albumin infusion

ANS: A The PAWP indicates that the patient's preload is elevated. Furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase the heart rate and myocardial oxygen demand. 5% albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.

A patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Decreased bowel sounds c. Heart rate 112 beats/min d. Pale, cool, and dry extremities

ANS: A The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to acute decompensated heart failure (ADHF)? a. Take medications as prescribed. b. Use oxygen when feeling short of breath. c. Direct questions only to the health care provider. d. Encourage most activity in the morning when rested.

ANS: A The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the medications as prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored by a care manager or in a transitional program to assess the patient for medication effectiveness and monitor for patient deterioration and encourage the patient. This nurse manager can be asked questions or can contact the health care provider if there is evidence of worsening HF.

When assessing a patient with increased extracellular fluid (ECF) osmolarity, the priority assessment for the nurse to obtain is a. mental status b. skin turgor c. capillary refill d. heart sounds

ANS: A a. mental status

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is high. b. The patient reports intermittent chest pressure. c. The patient's extremities are cool, and pulses are 1+. d. The patient has bilateral crackles throughout lung fields.

ANS: A The high serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient's diagnosis of cardiogenic shock.

A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient's care? A. Tadalafil (Cialas) B. Furosemide (Lasix) C. Warfarin (Coumadin) D. Diltiazem (Cardizem)

ANS: A The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using tadalafil because of the risk of severe hypotension caused by vasodilation. The other home medications should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment.

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective? A. "I will sit down before I put the nitroglycerin under my tongue." B. "I will check my pulse rate before I take any nitroglycerin tablets." C. "I will put the nitroglycerin patch on as soon as I get any chest pain." D. "I will remove the nitroglycerin patch before taking sublingual nitroglycerin."

ANS: A The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.

The nurse is preparing to administer a nitroglycerin patch to a patient. When providing teaching about the use of the patch, what should the nurse include? a. Avoid drugs to treat erectile dysfunction. b. Increase diet intake of high-potassium foods. c. Take an over-the-counter H2-receptor blocker. d. Avoid nonsteroidal antiinflammatory drugs (NSAIDS).

ANS: A The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. NSAIDs do not pose a risk in combination with nitrates. There is no need to take an H2-receptor blocker or increase the dietary intake of high-potassium foods.

A patient returns to the unit after a cardiac catheterization. Which nursing care would the registered nurse delegate to the unlicensed assistant personnel (UAP)? A. Take vital signs and report any abnormal values. B. Check for bleeding at the catheter insertion site. C. Prepare discharge teaching related to complications. D. Monitor the electrocardiogram for S-T segment changes.

ANS: A Vital signs should be delegated to the UAP. Assessment of the site, preparation of discharge teaching, and monitoring for S-T elevation would be registered nurse scope of practice.

During early assessment of the patient with an MI, the nurse is aware that which of the following diagnostic tests is the most important to determine the extent and treatment of an MI? a. Serial ECGs b. A chest X-ray c. Treadmill exercising d. Serum cardiac markers

ANS: A When the initial ECG is nondiagnostic, serial ECGs are done every 2 to 4 hours to determine the extent and treatment of an MI.

After having a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make? A. "What do you think caused your chest pain?" B. "Where are you planning to go for your vacation?" C. "Sometimes plans need to change after a heart attack." D. "Recovery from a heart attack takes at least a few weeks."

ANS: A When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.

To assist the patient with CAD to make the appropriate dietary changes, which of these nursing interventions will be most effective? a. Assist the patient to modify favorite high-fat recipes by using monounsaturated oils when possible. b. Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet. c. Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary. d. Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes.

ANS: A a. Assist the patient to modify favorite high-fat recipes by using monounsaturated oils when possible.

The nurse working in the emergency department (ED) admits a patient with hypovolemia and a serum potassium level of 8.0 mEq/L. All these orders are received from the health care provider. Which order will the nurse implement first? a. Place the patient on a cardiac monitor. b. Insert a retention catheter. c. Administer Kayexalate 15 g orally. d. Give IV furosemide (Lasix) 40 mg.

ANS: A a. Place the patient on a cardiac monitor.

A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is a. urine output of 0.5 mL/kg/hr b. decreased peripheral edema c. decreased CVP d. oxygen saturation 90% or more

ANS: A a. urine output of 0.5 mL/kg/hr

Which foods would the nurse encourage patients at risk for coronary artery disease (CAD) to include in their diets? (Select all that apply.) A. Tofu B. Walnuts C. Tuna fish D. Whole milk E. Orange juice

ANS: A, B, C Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital? (Select all that apply.) a. Ambulate postoperative patients as soon as possible after surgery. b. Use aseptic technique when manipulating invasive lines or devices. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Administer prescribed antibiotics within 1 hour for patients with possible sepsis. e. Advocate for parenteral nutrition for patients who cannot take in adequate calories.

ANS: A, B, C, D Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS.

A client who has experienced a myocardial infarction develops left ventricular heart failure. Which sign of poor organ perfusion should the nurse remain alert for? a. alanine aminotransferase (ALT) 122 u/L b. serum creatinine of 1.7 mg/dL c. urine output less than 30 mL/hour d. b & c e. a, b, c

ANS: A, B, C, E

A nurse is giving discharge instructions to a 77-year-old male client who had coronary artery bypass surgery. Which question should the nurse ask the client? a. "Do you still drive your car?" b. "What pain medications would you like to take at home?" c. "Any plan to be sexually involved?" d. "When was the last time you were hospitalized?"

ANS: C

A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take? (Select all that apply.) a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringer's solution. d. Provide high-flow O2 (100%) by nonrebreather mask. e. Prepare for emergent intubation and mechanical ventilation.

ANS: A, B, D, E All the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because an ischemic liver cannot convert lactate to bicarbonate.

A patient admitted with heart failure is anxious and reports shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety? (Select all that apply.) a. Administer ordered morphine sulfate. b. Position patient in a semi-Fowler's position. c. Position patient on left side with head of bed flat. d. Instruct patient on the use of relaxation techniques. e. Use a calm, reassuring approach while talking to patient.

ANS: A, B, D, E Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.

A nurse is teaching a client with CAD about care at home. The nurse knows that the objectives are achieved when the client states: Select all that apply. a. "My plan is to walk most days of the week for at least 20-30 minutes." b. "When I have chest pain, I will place a nitroglycerin tablet under my tongue." c. "I must always take 2-3 nitroglycerin tablets, 5 minutes apart." d. "I should carry my NTG in the glove compartment of my car." e. "I will not stay near to people when they are smoking."

ANS: A, B, E

A patient is admitted to the ICU with a diagnosis of NSTEMI. Which drug(s) would the nurse expect the patient to receive? (select all that apply) a. Oral statin therapy b. Antiplatelet therapy c. Thrombolytic therapy d. Prophylactic antibiotics e. Intravenous nitroglycerin

ANS: A, B, E

The client has a Hct of 22.3% and a hemoglobin of 7.7 g/dL. The HCP ordered two units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply. a. obtain a signed consent b. initiate a 22-gauge IV c. assess the client's lungs d. check for allergies e. hang a keep-open IV of D5W

ANS: A, C, D

The rhythm shows ventricular fibrillation. What interventions should the nurse anticipate? Select all that apply. a. prepare to administer the antidysrhythmic amiodarone (Cordarone) IV push b. prepare to administer digoxin IV push c. get ready to defibrillate the client d. start CPR

ANS: A, C, D

Which antilipemic medications should the nurse question for a patient who has cirrhosis of the liver? (Select all that apply.) A. Niacin B. Cholestyramine C. Ezetimibe (Zetia) D. Gemfibrozil (Lopid) E. Atorvastatin (Lipitor)

ANS: A, C, D, E Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently, and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply). a. assessing and identifying clients at risk b. monitoring the daily white blood cell count c. performing proper hand hygiene d. removing invasive lines as soon as possible e. using aseptic technique during procedures

ANS: A, C, D, E a. assessing and identifying clients at risk c. performing proper hand hygiene d. removing invasive lines as soon as possible e. using aseptic technique during procedures

A nurse cares for a HF client who has a regular rhythm of 118 beats/min. For which physiologic changes should the nurse assess? Select all that apply. a. decrease in urine output b. increase in cardiac output c. decrease in blood pressure d. decrease in cardiac output e. increase in blood pressure

ANS: A, D, E

The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient? (Select all that apply.) a. Left ventricular function is documented b. Controlling dysrhythmias will eliminate HF c. Prescription for digoxin (Lanoxin) at discharge d. Prescription for angiotensin-converting enzyme inhibitor at discharge e. Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen

ANS: A, D, E The Joint Commission has identified these 3 core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.

The nurse is teaching a patient recovering from a myocardial infarction. How should resumption of sexual activity be discussed? A. Delegated to the primary care provider B. Discussed along with other physical activities C. Avoided because it is embarrassing to the patient D. Accomplished by providing the patient with written material

ANS: B Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the patient's questions and concerns.

A patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about? (Select all that apply.) a. Strict hand washing. b. Daily nasal swabs for culture. c. Monitor temperature every hour. d. Daily skin care and oral hygiene. e. Encourage the patient to eat all foods to increase nutrients. f. Private room with a high-efficiency particulate air (HEPA) filter

ANS: A, D, F Strict hand washing and daily skin and oral hygiene must be done with neutropenia, because the patient is predisposed to infection from the normal body flora; other people; and uncooked meats, seafood, and eggs; unwashed fruits and vegetables; and fresh flowers or plants. The private room with HEPA filtration reduces the aerosolized pathogens in the patient's room. Blood cultures and antibiotic treatment are used when the patient has a temperature of 100.4° F or more, but temperature is not monitored every hour.

A hospitalized patient with a history of chronic stable angina tells the nurse that she is having chest pain. The nurse bases his actions on the knowledge that ischemia a. will always progress to myocardial infarction b. can be relieved by rest, nitroglycerin, or both c. is often associated with vomiting or extreme fatigue d. indicates that irreversible myocardial damage is occuring

ANS: B

A nurse finds a client pale, diaphoretic, dyspneic, and experiencing chest pain. What should the nurse do first? a. get PCA to take the client's vital signs while the nurse gets pain med b. apply O2, call for help and do a focused assessment c. stay with the client, call the charge nurse (CN) for help d. call a code

ANS: B

A nurse suspects that the client is having a myocardial infarction instead of angina upon finding a. depressed R wave on ECG b. an elevated ST segment c. the client reporting chest pain lasting more than 30 minutes d. few PVCs

ANS: B

After teaching about ways to decrease risk factors for coronary artery disease, the nurse recognizes that further instruction is needed when the patient says a. "I can keep my blood pressure normal with medication." b. "I would like to add weight lifting to my exercise program." c. "I can change my diet to decrease my intake of saturated fats." d. "I will change my lifestyle to reduce activities that increase my stress."

ANS: B

An 82-year-old client is admitted with a suspected myocardial infarction. What specific clinical manifestation of myocardial infarction would you expect to see in an older adult? b. disorientation or confusion

ANS: B

During treatment of the patient with an acute exacerbation of polycythemia vera, a critical action by the nurse is to a. check oxygen saturation q4hr b. monitor fluid intake and output c. place the patient on bed rest d. administer iron supplements

ANS: B

Intravenous nitroprusside (Nitride) is ordered for a patient with acute pulmonary edema. During the initial administration of the drug, the nurse monitors the patient for a. bradycardia b. hypotension c. cyanide toxicity d. ventricular arrhythmias

ANS: B

Nuclear imaging with radioactive isotopes is scheduled for a patient with chest pain. The nurse explains to the patient that this test will a. outline the blood flow through the chambers of the heart b. identify areas of ischemia or infarction of the heart muscle c. identify abnormalities in the heart wall motion and contraction d. evaluate the irritability of the heart and the risk for arrythmia

ANS: B

The nurse is administering medications on a cardiac unit. Which medication should the nurse question administering? a. Warfarin (Coumadin), an anticoagulant to a client with prothrombin time (PT) of 14 and an INR of 1.6 mg/dL b. Digoxin (Lanoxin), a cardiac glycoside to a client with potassium level 3.3 mEq/L c. Atenolol (Tenormin), a beta blocker, for the client with an aspirin Amino transfer is (AST) of 18 U/L d. Lisinopril (Zestril), an ace inhibitor for the client with a serum creatinine level of 0.8 mg/dL

ANS: B

The nurse is caring for a patient who is 2 days post MI. The patient reports that she is experiencing chest pain when she takes a deep breath. Which action would be a priority? a. Notify the provider STAT and obtain a 12-lead ECG. b. Obtain vital signs and auscultate for a pericardial friction rub. c. Apply high-flow O2 by face mask and auscultate breath sounds. d. Medicate the patient with as-needed analgesic and reevaluate in 30 minutes.

ANS: B

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump efficiently" is written. Which short term goal would be best for the client? The client will a. Be able to ambulate in the hall by date of discharge b. Have an audible S1 and S2 with no S3 heard by end of shift c. Turn, cough, and deep breathe every 2 hours d. Have a pulse oximeter reading of 98% by day two of care

ANS: B

While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on observing which of the following findings? a. cold, mottled extremities b. restlessness and apprehension c. a HR of 120 beats per min and cool, clammy skin d. a systolic BP less than 90 mm Hg and a widening pulse pressure

ANS: B

A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest? A. O2 saturation drops from 99% to 95%. B. Heart rate increases from 66 to 98 beats/min. C. Respiratory rate goes from 14 to 20 breaths/min. D. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.

ANS: B A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in O2 saturation, are normal responses to exercise.

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine? a. The patient is receiving low dose dopamine. b. The patient's central venous pressure is 3 mm Hg. c. The patient is in sinus tachycardia at 120 beats/min. d. The patient has had no urine output since admission.

ANS: B Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.

The nurse is caring for a patient who has just arrived on the telemetry unit after having cardiac catheterization. What task should the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? A. Teach the patient about the postprocedure plan of care. B. Give the scheduled aspirin and lipid-lowering medication. C. Perform the initial assessment of the catheter insertion site. D. Titrate the heparin infusion according to the agency protocol.

ANS: B Administration of oral medications is within the scope of practice for LPNs/VNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN).

A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix). What outcome would demonstrate medication effectiveness? a. Promote vasodilation. b. Reduction of preload. c. Decrease in afterload. d. Increase in contractility.

ANS: B Diuretics such as furosemide are used in the treatment of heart failure to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.

Before starting a transfusion of packed red blood cells, the nurse would arrange for a peer to monitor their other assigned patients for how many minutes when the nurse begins the transfusion? a. 5 b. 15 c. 30 d. 60

ANS: B As part of standard procedure, the nurse remains with the patient for the first 15 minutes after starting a blood transfusion. Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing. Monitoring during the transfusion will be every 30 to 60 minutes.

The blood bank notifies the nurse that 2 units of blood ordered for a patient is ready for pick up. Which action should the nurse take to prevent an adverse effect during this procedure? a. Immediately pick up both units of blood from the blood bank. b. Infuse the blood slowly for the first 15 minutes of the transfusion. c. Regulate the flow rate so that each unit takes at least 4 hours to transfuse. d. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.

ANS: B Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging 1 unit of blood. Only 1 unit of blood can be picked up at a time, it must be infused within 4 hours, and it cannot be hung with dextrose.

The nurse is developing a teaching plan for a 64-year-old patient with coronary artery disease (CAD). Which factor should the nurse focus on during the teaching session? A. Family history of coronary artery disease B. Elevated low-density lipoprotein (LDL) level C. Greater risk associated with the patient's gender D. Increased risk of cardiovascular disease with aging

ANS: B Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD.

A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104° F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Acetaminophen (Tylenol) 650 mg rectally. b. Administer normal saline IV at 500 mL/hr. c. Start norepinephrine to keep blood pressure above 90 mm Hg. d. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.

ANS: B Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate and should be initiated quickly as well.

To improve the physical activity level for a mildly obese 68-year-old patient, which action should the nurse plan to take? A. Stress that weight loss is a major benefit of increased exercise. B. Determine what kind of physical activities the patient usually enjoys. C. Tell the patient that older adults should exercise for no more than 20 minutes at a time. D. Teach the patient to include a short warm-up period at the beginning of physical activity.

ANS: B Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults.

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching.

ANS: B Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is from an acute myocardial infarction? A. The pain increases with deep breathing. B. The pain has lasted longer than 30 minutes. C. The pain is relieved after the patient takes nitroglycerin. D. The pain is reproducible when the patient raises the arms.

ANS: B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient? a. Administration of packed red blood cells b. Administration of oral or IV corticosteroids c. Administration of clotting factors VIII and IX d. Maintenance of reverse isolation and application of standard precautions

ANS: B Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Standard precautions are used with all patients

The nurse is caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI). What should the nurse anticipate teaching the patient? A.Sudden cardiac death events rarely reoccur. B. Additional diagnostic testing will be required. C. Long-term anticoagulation therapy will be needed. D. Limiting physical activity will prevent future SCD events.

ANS: B Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting.

What should the nurse recognize as an indication for the use of dopamine in the care of a patient with heart failure? a. Acute anxiety b. Hypotension and tachycardia c. Peripheral edema and weight gain d. Paroxysmal nocturnal dyspnea (PND)

ANS: B Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.

The nurse prepares a discharge teaching plan for a patient who has recently been diagnosed with coronary artery disease (CAD). Which priority risk factor should the nurse plan to focus on during the teaching session? A. Type A personality B. Elevated serum lipids C. Family cardiac history D. High homocysteine levels

ANS: B Dyslipidemia is one of the four major modifiable risk factors for CAD. The other major modifiable risk factors are hypertension, tobacco use, and physical inactivity. Research findings related to psychological states (i.e., type A personality) as a risk factor for coronary artery disease have been inconsistent. Family history is a non modifiable risk factor. High homocysteine levels have been linked to an increased risk for CAD.

The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. What should teaching for this patient include today? A. Typical emotional responses to AMI B. When cardiac rehabilitation will begin C. Pathophysiology of coronary artery disease D. Information regarding discharge medications

ANS: B Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease. Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction.

The following interventions are prescribed by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Give diphenhydramine. b. Administer epinephrine. c. Start continuous ECG monitoring. d. Draw blood for complete blood count.

ANS: B Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones completed.

The nurse would recognize which assessment finding as suggestive of sepsis? a. Sudden diuresis unrelated to drug therapy b. Hyperglycemia in the absence of diabetes c. Respiratory rate of seven breaths per minute d. Bradycardia with sudden increase in blood pressure

ANS: B Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia.

A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and now has bleeding in the left knee joint. What should be the emergency nurse's immediate action? a. Immediate transfusion of platelets b. Resting the patient's knee to prevent hemarthroses c. Assistance with intracapsular injection of corticosteroids d. Range-of-motion exercises to prevent thrombus formation

ANS: B In patients with hemophilia, joint bleeding requires resting of the joint to prevent deformities from hemarthrosis. Clotting factors, not platelets or corticosteroids, are administered. Thrombus formation is not a central concern in a patient with hemophilia.

A patient has anemia related to inadequate intake of essential nutrients. Which intervention would be appropriate for the nurse to include in the plan of care for this patient? a. Plan for 30 minutes of rest before and after every meal. b. Encourage foods high in protein, iron, vitamin C, and folate. c. Teach the patient to select only soft, bland, and nonacidic foods. d. Give the patient a list of medications that inhibit iron absorption.

ANS: B Increased intake of protein, iron, folate, and vitamin C provides nutrients needed for maximum iron absorption and hemoglobin production. The other interventions do not address the patient's identified problem of inadequate intake of essential nutrients. Selection of foods that are soft, bland, and nonacidic is appropriate if the patient has oral mucosal irritation. Scheduled rest is an appropriate intervention if the patient has fatigue related to anemia. Providing information about medications that may inhibit iron absorption (e.g., antacids, tetracycline, soft drinks, tea, coffee, calcium, phosphorus, and magnesium salts) is important but does not address the patient's problem of inadequate intake of essential nutrients.

A patient is admitted to the emergency department vomiting bright red blood. The patient's vital signs are BP of 78/58 mm Hg, pulse of 124 beats/min, respirations of 28 breaths/min, and temperature of 97.2° F (36.2° C). Which provider order should the nurse complete first? a. Obtain a 12-lead ECG and arterial blood gases. b. Rapidly administer 1000 mL normal saline solution IV. c. Start norepinephrine (Levophed) by continuous IV infusion. d. Insert a nasogastric tube and an indwelling bladder catheter.

ANS: B Isotonic crystalloids, such as normal saline solution, should be used in the initial resuscitation of hypovolemic shock. Vasopressor drugs (e.g., norepinephrine) may be considered if the patient does not respond to fluid resuscitation and blood products. Other orders (e.g., insertion of nasogastric tube and indwelling bladder catheter and obtaining the diagnostic studies) can be done after fluid resuscitation is started.

A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient? a. Start IV fluids. b. Maintain oxygenation. c. Maintain distal warmth. d. Check peripheral pulses.

ANS: B Maintaining oxygenation is a priority as sickling episodes are frequently triggered by low oxygen tension in the blood which is commonly caused by an infection. Antibiotics to treat cellulitis, pain control, and fluids to reduce blood viscosity will also be used, but oxygenation is the priority.

When caring for a critically ill patient who is being mechanically ventilated, the nurse will monitor for which manifestation of multiple organ dysfunction syndrome (MODS)? a. Increased serum albumin b. Decreased respiratory compliance c. Increased gastrointestinal (GI) motility d. Decreased blood urea nitrogen (BUN)/creatinine ratio

ANS: B Manifestations of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decreased GI motility, acute neurologic changes, myocardial dysfunction, disseminated intravascular coagulation (DIC), and changes in glucose metabolism.

The home care nurse visits a patient with chronic heart failure. Which assessment findings would indicate acute decompensated heart failure (pulmonary edema)? a. Fatigue, orthopnea, and dependent edema b. Severe dyspnea and blood-streaked, frothy sputum c. Temperature is 100.4° F and pulse is 102 beats/min d. Respirations 26 breaths/min despite oxygen by nasal cannula

ANS: B Manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate greater than 30 breaths/min, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles b. Heart rate 45 beats/min c. Cool, clammy extremities d. Temperature 101.2° F (38.4° C)

ANS: B Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

Which patient statement indicates that the nurse's teaching about carvedilol (Coreg) for preventing anginal episodes has been effective? A. "Carvedilol will help my heart muscle work harder." B. "It is important not to suddenly stop taking the carvedilol." C. "I can expect to feel short of breath when taking carvedilol." D. "Carvedilol will increase the blood flow to my heart muscle."

ANS: B Patients who have been taking B-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking B-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O2 demand, not by increasing blood flow to the coronary arteries.

The nurse is caring for a patient with polycythemia vera. What is an important action for the nurse to initiate? a. Encourage deep breathing and coughing. b. Assist with or perform phlebotomy at the bedside. c. Teach the patient how to maintain a low-activity lifestyle. d. Perform thorough and regularly scheduled neurologic assessments.

ANS: B Primary polycythemia vera often requires phlebotomy in order to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep breathing and coughing exercises do not directly address the etiology or common sequelae of polycythemia, and neurologic manifestations are not typical.

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? A. Hyperglycemia B. Bilateral crackles C. Q waves on ECG D. Elevated troponin

ANS: B Pulmonary congestion suggests that the patient may be developing heart failure, a complication of myocardial infarction (MI). Hyperglycemia is common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI.

A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about safely resuming sexual intercourse. Which response by the nurse is best? A. "Most patients are able to enjoy intercourse without any complications." B. "Sexual activity uses about as much energy as climbing two flights of stairs." C. "The doctor will provide sexual guidelines when your heart is strong enough." D. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

ANS: B Sexual activity places about as much physical stress on the cardiovascular system as moderate-energy activities, such as climbing two flights of stairs. The other responses are general statements that may be accurate, but do not provide useful guidelines for judging the physical safety of the activity.

Which person would the nurse identify as having the highest risk for coronary artery disease (CAD)? A. A 60-yr-old man with low homocysteine levels B. A 45-yr-old man with a high-stress job who is depressed C. A 54-yr-old woman vegetarian with increased high-density lipoprotein (HDL) levels D. A 62-yr-old woman who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

ANS: B The 45-yr-old depressed man with a high-stress job is at the highest risk for CAD. Depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-lb weight gain in the past 3 days. What is the nurse's priority action? a. Teach the patient about restricting dietary sodium. b. Assess the patient for manifestations of acute heart failure. c. Ask the patient about the use of the prescribed medications. d. Have the patient recall the dietary intake for the past 3 days.

ANS: B The 5-lb weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

A patient with an acute peptic ulcer and major blood loss requires an immediate transfusion with packed red blood cells. Which task is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Confirm the IV solution is 0.9% saline. b. Obtain the vital signs before the transfusion is initiated. c. Monitor the patient for shortness of breath and back pain. d. Double-check the patient identity and verify the blood product.

ANS: B The RN may delegate tasks such as taking vital signs to UAP. Assessments (e.g., monitoring for signs of a blood transfusion reaction [shortness of breath and back pain]) are within the scope of practice of the RN and may not be delegated to UAP. The RN must also assume responsibility for ensuring the correct IV fluid is used with blood products. A licensed nurse must complete verification of the patient's identity and the blood product data.

Which assessment finding in a patient who has had coronary artery bypass grafting using a right radial artery graft is most important for the nurse to communicate to the health care provider? A. Complaints of incisional chest pain B. Pallor and weakness of the right hand C. Fine crackles heard at both lung bases D. Redness on both sides of the sternal incision

ANS: B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions, such as prescribed calcium channel blockers or surgery. The other changes are expected or require nursing interventions.

Which topic will the nurse plan to include in discharge teaching for a patient who has heart failure with reduced ejection fraction (HFrEF)? a. Need to begin an aerobic exercise program several times weekly b. Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors c. Use of salt substitutes to replace table salt when cooking and at the table d. Importance of making an annual appointment with the health care provider

ANS: B The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction below 40% should receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure. Salt substitutes are not usually recommended because of the risk of hyperkalemia. The patient will need to see the primary care provider more often than annually.

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Provide O2 at 100% per non-rebreather mask. c. Draw blood to type and crossmatch for transfusions. d. Initiate continuous electrocardiogram (ECG) monitoring.

ANS: B The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize O2 delivery have been implemented.

The nurse receives a provider's order to transfuse fresh frozen plasma to a patient with acute blood loss. Which procedure is most appropriate for infusing this blood product? a. Hang the fresh frozen plasma with lactated Ringer's solution. b. Fresh frozen plasma must be given within 24 hours after thawing. c. Infuse the fresh frozen plasma at a rate of 50 mL/hr for the duration. d. Hang the fresh frozen plasma as a piggyback to a primary IV solution without KCl.

ANS: B The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in factors V and VIII. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.

Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a myocardial infarction (MI)? A. Monitor heart rate. B. Ask about chest pain. C. Check blood pressure. D. Observe for dysrhythmias.

ANS: B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse will also monitor heart rate and blood pressure and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

Which patient at the cardiovascular clinic requires the most immediate action by the nurse? A. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL. B. Patient with stable angina whose chest pain has recently increased in frequency. C. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL. D. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg.

ANS: B The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are more stable.

A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. check the blood pressure. b. obtain an oxygen saturation. c. attach a cardiac monitor. d. check level of consciousness.

ANS: B b. obtain an oxygen saturation.

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What is the priority action by the nurse? a. Withhold the daily dose until the following day. b. Withhold the dose and report the potassium level. c. Give the digoxin with a salty snack, such as crackers. d. Give the digoxin with extra fluids to dilute the sodium level.

ANS: B The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and wait for the potassium level to normalize. The provider may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.

The nurse notes a provider's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time? a. 11:45 AM b. 12:00 noon c. 12:30 PM d. 3:30 PM

ANS: B The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank.

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first? a. A patient who reported dizziness after receiving the first dose of captopril. b. A patient who has new-onset confusion and restlessness and cool, clammy skin. c. A patient who is receiving oxygen and has crackles bilaterally in the lung bases. d. A patient who is receiving IV nesiritide (Natrecor), with a blood pressure of 100/62.

ANS: B The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion.

When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What associated clinical manifestations does the nurse anticipate observing? a. Thirst b. Fatigue c. Headache d. Abdominal pain

ANS: B The patient with a low hemoglobin and hematocrit is anemic and would likely have fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions. Thirst, headache, and abdominal pain are not related to anemia.

A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mm Hg, a pulse of 64 beats/min, and a high pulmonary artery wedge pressure (PAWP). Which intervention prescribed by the health care provider should the nurse question? a. Elevate head of bed to 30 degrees. b. Infuse normal saline at 250 mL/hr. c. Hold nitroprusside if systolic BP is less than 90 mm Hg. d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

ANS: B The patient's elevated PAWP indicates volume excess in relation to cardiac pumping ability, consistent with cardiogenic shock. A saline infusion at 250 mL/hr will worsen the volume excess. The other actions will help to improve cardiac output, which should lower the PAWP and may raise the BP.

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. Patient who is taking carvedilol (Coreg) and has a heart rate of 58. b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L. c. Patient who is taking captopril and has a frequent nonproductive cough. d. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache.

ANS: B The patient's low potassium level increases the risk for digoxin toxicity and potentially life-threatening dysrhythmias. The nurse should assess the patient for other signs of digoxin toxicity and then notify the health care provider about the potassium level. The other patients also have side effects of their drugs, but their symptoms do not indicate potentially life-threatening complications.

The nurse is examining the electrocardiogram (ECG) of a patient just admitted with a suspected myocardial infarction (MI). Which ECG change is most indicative of prolonged or complete coronary occlusion? A. Sinus tachycardia B. Pathologic Q wave C. Fibrillatory P waves D. Prolonged PR interval

ANS: B The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? A. "I will replace my nitroglycerin supply every 6 months." B. "I can take up to 5 tablets every 3 minutes for relief of my chest pain." C. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." D. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

ANS: B The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or 1 metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of 3 doses and contact EMS if symptoms have not resolved completely.

A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective? a. No heart murmur b. Skin is warm and pink c. Decreased troponin level d. Blood pressure of 92/40 mm Hg

ANS: B Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.

The nurse is evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery. Which patient statement indicates that additional teaching is needed? A. "They will circulate my blood with a machine during surgery." B. "I will have incisions in my leg where they will remove the vein." C. "They will use an artery near my heart to go around the area that is blocked." D. "I will need to take aspirin every day after the surgery to keep the graft open."

ANS: B When the internal mammary artery is used, there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.

A 68-year-old man has a long history of COPD and is admitted to the hospital with cor pulmonale. Which clinical manifestation noted by the nurse is consistent with the cor pulmonale diagnosis? a. Audible crackles at both lung bases b. 3+ edema in the lower extremities c. Loud murmur at the mitral area d. High systemic BP

ANS: B b. 3+ edema in the lower extremities

A patient who has been involved in a motor-vehicle crash is admitted to the ER with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first? a. Insert two 14-gauge IV catheters b. Administer oxygen at 100% per non-rebreather mask c. Place the patient on continuous cardiac monitor d. Draw blood to type and crossmatch for transfusions

ANS: B b. Administer oxygen at 100% per non-rebreather mask

A client presents with a history of variant (Prinzmetal's angina). What symptoms would you expect to be manifested in this client? a. Chest discomfort that appears with exertion and is relieved with nitroglycerine b. Chest pain occurring with minimal exertion that limits the client's activity c. A burning sensation in the chest wall that is relieved with rest d. Chest pressure or tightness that radiates to the arm and jaw

ANS: B b. Chest pain occurring with minimal exertion that limits the client's activity

When a person's hemoglobin is deficient in iron, which assessment finding is expected? a. Cherry red lips and mucous membranes b. Increased respiratory rate c. Slow capillary refill d. Decreased heart rate

ANS: B b. Increased respiratory rate

The nurse obtains all of the following assessment data about a patient with fluid-volume deficit. Which of the following assessment data will be of greatest concern? a. Oral fluid intake is 100 mL for the last 8 hours. b. The blood pressure is 90/40 mm Hg. c. Urine output is 30 mL over the last hour. d. There is prolonged skin tenting over the sternum.

ANS: B b. The blood pressure is 90/40 mm Hg.

A nurse is taking the history of a client with suspected coronary artery disease. Recently, the client has had episodes of chest discomfort while mowing the lawn with a push mower. The chest discomfort subsides when the client rests. What conclusion can you draw from this information? a. The client may have variant angina b. The client may have stable angina c. The client may have had a myocardial infarction d. The client need not be concerned about this pain, because it is relieved with rest

ANS: B b. The client may have stable angina

After assessing a client on Cordarone infusion for V. tach, the nurse documents the findings and compares these with the previous assessment findings. Based on the findings, which action should the nurse take? Vital signs: Time: 0900 Temperature 98 F, Heart rate 68 bpm, Blood pressure 135/60 mm Hg, Respiratory rate 14 breaths/min, Oxygen saturation 96%, Oxygen therapy 2 L nasal cannula Time: 11:59 am Temperature 98.2 F, Heart rate 50 bpm, Blood pressure 132/57 mm Hg, Respiratory rate 16 breaths/min, Oxygen saturation 95%, Oxygen therapy 2 L nasal cannula Nursing assessments: Time: 0900 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 11:59 am Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. a. Ask the client to take deep breaths b. Titrate the infusion rate down c. End the infusion and flush the IV d. Administer D5W

ANS: B b. Titrate the infusion rate down

A patient receiving a whole-blood transfusion develops chills and fever, headache, and anxiety 30 minutes after the transfusion is started. After stopping the transfusion the nurse will plan to a. send a urine specimen to the lab b. administer acetaminophen (Tylenol) c. give diphenhydramine (Benadryl) d. notify HCP of the transfusion reaction

ANS: B b. administer acetaminophen (Tylenol)

When caring for an alert and oriented elderly patient with a history of dehydration (hypovolemia), the home health nurse will teach the patient to increase fluid intake a. in the late evening hours b. if the oral mucosa feels dry c. when the patient feels thirsty d. as soon as changes in level of consciousness (LOC) occur

ANS: B b. if the oral mucosa feels dry

During treatment of the patient with an acute exacerbation of polycythemia vera, a critical action by the nurse is to a. check oxygen saturation q4hr. b. monitor fluid intake and output. c. place the patient on bed rest. d. administer iron supplements.

ANS: B b. monitor fluid intake and output.

A nurse is discharging a male client following a MI with stenting and subsequent quadruple bypass graft. The client has a body mass index of 34, has HTN, smokes 2 packs per day of cigarettes, and has prescriptions for ASA, clopidogrel bisulfate, atenolol, and atorvastatin. Which discharge instructions are most appropriate? Select all that apply. a. Discontinue the atenolol when your heart rate is less than 60 beats per minute. b. Use a soft toothbrush and electric razor because you can bleed easily. c. Minimize or discontinue your alcohol intake. d. Discontinue the use of elastic stockings (TEDS). e. Begin smoking cessation once your incision is completely healed.

ANS: B, C

The nurse is about to administer the fourth unit of PRBCs to a client with severe anemia. Which interventions should the nurse implement? Select all that apply. A. Get a warmer for the blood B. Use a new blood transfusion set C. Obtain vital signs D. Change IV to D5NS to keep vein open E. Assess for allergies to blood products

ANS: B, C

The nurse would assess a patient with reports of chest pain for which clinical manifestations associated with a myocardial infarction (MI)? (Select all that apply.) A. Flushing B. Ashen skin C. Diaphoresis D. Nausea and vomiting E. S3 or S4 heart sounds

ANS: B, C, D, E During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) because of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.

A nurse is teaching a client newly diagnosed with chronic stable angina. Which instructions should the nurse incorporate in the teaching session on measures to prevent future angina? Select all that apply. a. increase isometric arm exercises to build endurance b. wear a face mask when outdoors in cold weather c. take nitroglycerin before a stressful situation even though pain is not present d. perform most exertional activities in the morning e. avoid straining at stool f. eliminate tobacco use

ANS: B, C, E, F

A client with a Hgb of 7.2 g/dL refuses transfusions because of his Jehovah witness beliefs. What may the HCP prescribe? Select all that apply. a. Frozen plasma b. Folic acid c. Albumin d. Procrit e. Platelets

ANS: B, D

A 78-year-old man is brought by his family to the ER because he developed severe weakness and difficulty breathing at home. During assessment of the patient's cardiovascular status a nurse is aware that coronary artery disease in patients this age a. may be mistaken for normal physiological age related changes in the heart b. rarely cause death because of collateral circulation c. often manifest without the usual chest pain and diaphoresis characteristics of myocardial ischemia d. cannot be controlled with lifestyle changes such as stop smoking and initiate exercise program

ANS: C

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "Some of the medications we are giving are to raise blood sugar." b. "The IV solution has lots of glucose, which raises blood sugar." c. "High glucose is common in shock and needs to be treated." d. "The stress of this illness has made your spouse a diabetic."

ANS: C

A nurse cares for a client with a long smoking history. Assessment findings include distended neck veins and dependent edema. Which findings match the client's history and clinical presentation? a. exposure to allergens b. increased number and size of mucus glands producing large amounts of thick mucus c. increased pressure in the pulmonary system d. left ventricular hypertrophy creating a decrease in cardiac output

ANS: C

A nurse evaluates all seriously ill clients for the development of DIC, based on the knowledge that a. DIC is a thrombotic disease occurring because of the loss of fibrinolytic agents. b. DIC is a systemic disorder in which necrotic tissues stimulate the overproduction of fibrinolytic agents. c. DIC is a bleeding disorder as a result of reduction of platelets and clotting factors. d. DIC is a disease of the blood in which there is an overproduction of clotting factors.

ANS: C

A patient is recovering from an uncomplicated myocardial infarction. Which rehabilitation guideline is a priority to include in the teaching plan? a. Refrain from sexual activity for a minimum of 3 weeks. b. Plan a diet program that aims for a 1- to 2-lb weight loss per week. c. Begin an exercise program that aims for at least five 30 minute sessions per week. d. Consider the use of erectile agents and prophylactic nitroglycerin before engaging in sexual activity.

ANS: C

During a blood transfusion a client experiences anxiety and flank pain. After discontinuing the transfusion, what action by the nurse is most important? a. Entering the events in the client's medical record. b. Rechecking the client's medical record for any allergies. c. Verifying the client and blood product identification. d. Administer morphine IV to control the pain and anxiety.

ANS: C

The RN and an experienced LPN are caring for a group of clients. Which nursing task should be assigned to the LPN? a. Evaluate the client diagnosed with stage IV heart failure b. Discharge the client who had a negative breast biopsy c. Feed the client who has both hands bandaged d. Administer the IVP analgesic

ANS: C

The most common finding in people at risk for sudden cardiac death is a. aortic valve disease b. mitral valve disease c. left ventricular dysfunction d. atherosclerotic heart disease

ANS: C

The nurse is administering medications at 1800 and uses the following medication administration record (MAR). Which intervention should the nurse implement first? a. Assess the pt's potassium and digoxin levels b. Monitor the pt's partial thromboplastin time c. Check the client's INR d. Verify the client's name and identification number with the MAR

ANS: C

The nurse is administering medications to clients on a cardiac unit. Which medication should a nurse question administering? a. the loop diuretic furosemide (Lasix) to a client who had a 320 mL output in 4 hours b. the anticoagulant (Lovenox) to a client who had open heart surgery c. the antiplatelet ticlopidine (Ticlid) to a client being prepared for surgery d. the ace inhibitor captopril (Capoten) to a client who has a BP of 100/68

ANS: C

The patient you were assigned to has a history of a murmur caused by mitral prolapse. The nurse would assess and validate this data by auscultating the a. right and left sternal borders at the 2nd intercostal space b. right of the sternal border at the 3rd intercostal space c. left of the sternal border, 5th intercostal space, midclavicular line d. right of the sternal border, 4th intercostal space e. right and left of the sternal border, 4th intercostal space

ANS: C

When reading the chart for a patient with COPD, the nurse notes that the patient has cor pulmonale. To assess for cor pulmonale, the nurse will monitor the patient for a. elevated temperature b. complaints of chest pain c. jugular vein distention d. clubbing of the fingers

ANS: C

Which data should the nurse question before administering digoxin? a. The digoxin level is 1.1 ng/mL b. The client's apical heart rate is 64. c. The potassium level is 3.4 mEq/L. d. The client denies nausea & vomiting.

ANS: C

Why is the administration of aspirin recommended along with nitroglycerin when a client is experiencing angina-like chest pain? a. aspirin has analgesic properties without sedation b. aspirin can trigger vasodilation and improve blood flow c. aspirin inhibits platelet aggregation and clot involvement d. aspirin has cardiotonic properties and improves contraction

ANS: C

The nurse is assigned to care for several patients on a medical unit. Which patient should the nurse assess first? a. A 60-yr-old patient with a blood pressure of 92/64 mm Hg and hemoglobin of 9.8 g/dL b. A 50-yr-old patient with a respiratory rate of 26 breaths/minute and an elevated D-dimer c. A 40-yr-old patient with a temperature of 100.8°F (38.2°C) and a neutrophil count of 256/µL d. A 30-yr-old patient with a pulse of 112 beats/min and a white blood cell count of 14,000/µL

ANS: C A low-grade fever greater than 100.4° F (38° C) in a patient with a neutrophil count below 500/µL is a medical emergency and may indicate an infection. An infection in a neutropenic patient could lead to septic shock and possible death if not treated immediately.

A patient with a suspected brain tumor is scheduled for a CT scan with contrast media. The nurse notifies the provider that the patient reported an allergy to shellfish. Which response by the provider should the nurse question? a. Complete the CT scan without contrast media. b. Give IV diphenhydramine before the procedure. c. Give IV lorazepam (Ativan) before the procedure. d. Premedicate with hydrocortisone sodium succinate.

ANS: C A person with an allergy to shellfish is at an increased risk to develop anaphylactic shock if contrast media is injected for a CT scan. To prevent anaphylactic shock, the nurse should always confirm the patient's allergies before diagnostic procedures (e.g., CT scan with contrast media). Appropriate interventions may include cancelling the procedure, completing the procedure without contrast media, or premedication with diphenhydramine or hydrocortisone. IV fluids may be given to promote renal clearance of the contrast media and prevent renal toxicity and acute kidney injury. The use of an antianxiety agent such as lorazepam would not be effective in preventing an allergic reaction to the contrast media.

What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? a. Urine output b. Lung sounds c. Blood pressure d. Respiratory rate

ANS: C Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.

After having a myocardial infarction (MI), the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108 beats/min. What should the nurse suspect is happening? a. Chronic HF b. Left-sided HF c. Right-sided HF d. Acute decompensated HF

ANS: C An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.

A patient who is receiving dobutamine for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)? a. Teach the patient the reasons for remaining on bed rest. b. Change the peripheral IV site according to agency policy. c. Monitor the patient's blood pressure and heart rate every hour. d. Titrate the dobutamine to keep the systolic blood pressure >90 mm Hg.

ANS: C An experienced LPN/VN would be able to monitor BP and heart rate and would know to report significant changes to the RN. Teaching patients, adjusting the drip rate for vasoactive drugs, and inserting a new peripheral IV catheter require RN level education and scope of practice.

The nurse is administering a dose of Digitalis (digoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom? a. Muscle aches b. Constipation c. Loss of appetite d. Pounding headache

ANS: C Anorexia, nausea, vomiting, blurred or yellow vision, and dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.

After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases. b. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/min. c. Patient with suspected urosepsis who has new prescriptions for urine and blood cultures and antibiotics. d. Patient admitted with anaphylaxis 3 hours ago who has clear lung sounds and a blood pressure of 108/58 mm Hg.

ANS: C Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not need immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually need treatment in patients with a spinal cord injury. The findings for the patient admitted with anaphylaxis show resolution of bronchospasm and hypotension.

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. There are no signs of hemorrhage. b. Hemoglobin is within normal limits. c. Urine output 65 mL over the past hour. d. Mean arterial pressure (MAP) is 72 mm Hg.

ANS: C Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. The absence of hemorrhage helps to prevent further fluid loss but does not reflect fluid balance.

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum troponin b. Arterial blood gases c. B-type natriuretic peptide d. 12-lead electrocardiogram

ANS: C B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure. A 12-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? a. Weight loss of 2 lb in 24 hours b. Hourly urine output greater than 60 mL c. Reduced dyspnea with the head of the bed at 30 degrees d. Patient denies experiencing chest pain or chest pressure

ANS: C Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data may also indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patient's response.

The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration? a. Unit secretary b. A physician's assistant c. Another registered nurse d. An unlicensed assistive personnel

ANS: C Before hanging a transfusion, the registered nurse must check the unit with another RN or with a licensed practical (vocational) nurse, depending on agency policy. The unit secretary, physician's assistant, or unlicensed assistive personnel should not be asked.

The nurse recognizes additional teaching is needed when the patient prescribed a low-sodium, low-fat cardiac diet selects which food? A. Baked flounder B. Angel food cake C. Canned chicken noodle soup D. Baked potato with margarine

ANS: C Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.

A patient with chronic heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. "I plan to take the medication with food." b. "I should eat more potassium-rich foods." c. "I will call for help when I need to get up to use the bathroom." d. "I can expect to feel more short of breath for the next few days."

ANS: C Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of -adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

Which information about a patient receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider? A. An increase in troponin levels from baseline B. A large bruise at the patient's IV insertion site C. No change in the patient's reported level of chest pain D. A decrease in ST-segment elevation on the electrocardiogram

ANS: C Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring, and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac biomarkers into the circulation as the blocked vessel is opened.

Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient? A. "Heparin enhances platelet aggregation at the plaque site." B. "Heparin decreases the size of the coronary artery plaque." C. "Heparin prevents the development of new clots in the coronary arteries." D. "Heparin dissolves clots that are blocking blood flow in the coronary arteries."

ANS: C Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

A patient who has heart failure has recently started taking digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1+ to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days

ANS: C Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions) and potentiate the actions of digoxin. Hypokalemia also increases the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

A 74-yr-old man with a history of prostate cancer and hypertension is admitted to the emergency department with substernal chest pain. Which priority action will the nurse complete before administering sublingual nitroglycerin? A. Administer morphine sulfate IV. B. Auscultate heart and lung sounds. C. Obtain a 12-lead electrocardiogram (ECG). D. Assess for coronary artery disease risk factors.

ANS: C If a patient has chest pain, the nurse should institute the following measures: (1) administer supplemental oxygen and position the patient in upright position unless contraindicated, (2) assess vital signs, (3) obtain a 12-lead ECG, (4) provide prompt pain relief first with a nitrate followed by an opioid analgesic if needed, and (5) auscultate heart sounds. Obtaining a 12-lead ECG during chest pain aids in the diagnosis.

A patient's localized infection has become systemic and septic shock is suspected. What medication would be given to treat septic shock refractory to fluids? a. Insulin infusion b. Furosemide IV push c. Norepinephrine administered by titration d. Administration of nitrates and β-adrenergic blockers

ANS: C If fluid resuscitation using crystalloids is not effective, vasopressor medications, such as norepinephrine (Levophed) and dopamine, are indicated to restore mean arterial pressure (MAP). Nitrates and β-adrenergic blockers are most often used in the treatment of patients in cardiogenic shock. Furosemide (Lasix) is indicated for patients with fluid volume overload. Insulin infusion may be given to normalize blood sugar and improve overall outcomes, but it is not considered a medication used to treat shock.

A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is an option. Which response is accurate? a. "Your heart failure has not reached the end stage yet." b. "You could not manage the multiple complications of that surgery." c. "The suitability of a heart transplant for you depends on many factors." d. "Because you have diabetes, you would not be a heart transplant candidate."

ANS: C Indications for a heart transplant include end-stage heart failure (stage D), but other factors such as coping skills, family support, and patient motivation to follow the rigorous post transplant regimen are also considered. Patients with diabetes who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, there are no data to suggest that the patient could not manage the care.

Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes? A. Inform the patient about a diet containing no saturated fat and minimal salt. B. Emphasize the increased cardiac risk unless the patient makes dietary changes. C. Help the patient modify favorite high-fat recipes by using monounsaturated oils. D. Give the patient a list of low-sodium, low-cholesterol foods to include in the diet.

ANS: C Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monounsaturated or polyunsaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

The nurse knows that hemolytic anemia can be caused by which extrinsic factors? a. Trauma or splenic sequestration crisis b. Abnormal hemoglobin or enzyme deficiency c. Macroangiopathic or microangiopathic factors d. Chronic diseases or medications and chemicals

ANS: C Macroangiopathic or microangiopathic extrinsic factors lead to acquired hemolytic anemias. Trauma or splenic sequestration crisis can lead to anemia from acute blood loss. Abnormal hemoglobin or enzyme deficiency are intrinsic factors that lead to hereditary hemolytic anemias. Chronic diseases or medications and chemicals can decrease the number of red blood cell (RBC) precursors which reduce RBC production.

The nurse prepares to administer digoxin 0.125 mg to a patient admitted with influenza and a history of chronic heart failure. What should the nurse assess before giving the medication? a. Prothrombin time b. Urine specific gravity c. Serum potassium level d. Hemoglobin and hematocrit

ANS: C Serum potassium should be monitored because hypokalemia increases the risk for digoxin toxicity. Changes in prothrombin time, urine specific gravity, and hemoglobin or hematocrit would not require holding the digoxin dose.

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Which instruction should the nurse include? a. Limit dietary sources of potassium. b. Take the hydrochlorothiazide at bedtime. c. Notify the health care provider if nausea develops. d. Take the digoxin if the pulse is below 60 beats/min.

ANS: C Nausea is a symptom of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60 beats/min, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate? a. Increase the rate for the dopamine infusion. b. Decrease the rate for the nitroglycerin infusion. c. Increase the rate for the sodium nitroprusside infusion. d. Decrease the rate for the 5% dextrose in normal saline infusion.

ANS: C Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" How should the nurse document this finding? a. Orthopnea b. Pulsus alternans c. Paroxysmal nocturnal dyspnea d. Acute bilateral pleural effusion

ANS: C Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alteration of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.

Which data indicates to the nurse that the patient with stable angina is experiencing a side effect of metoprolol (Lopressor)? A. Patient is restless and agitated. B. Patient reports feeling anxious. C. Blood pressure is 90/54 mm Hg. D. Heart monitor shows normal sinus rhythm.

ANS: C Patients taking B-adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. Normal sinus rhythm is a normal and expected heart rhythm.

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients with shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Maintaining a cool room temperature for a patient with neurogenic shock d. Increasing the nitroprusside for a patient with cardiogenic shock and a high SVR

ANS: C Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

The nurse is caring for a patient who was admitted 1 week ago with multiple rib fractures, pulmonary contusions, and a left femur fracture from a motor vehicle crash. The provider states the patient has developed sepsis, and the family members have many questions. Which information should the nurse include when explaining the early stage of sepsis? a. Weaning the patient from the ventilator is the top priority in sepsis. b. Antibiotics are not useful when an infection has progressed to sepsis. c. Large amounts of IV fluid are required in sepsis to fill dilated blood vessels. d. The patient has recovered from sepsis if he has warm skin and ruddy cheeks.

ANS: C Patients with sepsis may be normovolemic, but because of acute vasodilation, relative hypovolemia and hypotension occur. Patients in septic shock require large amounts of fluid replacement and may require frequent fluid boluses to maintain circulation. Antibiotics are an important component of therapy for patients with septic shock. They should be started after cultures (e.g., blood, urine) are obtained and within the first hour of septic shock. Oxygenating the tissues is the top priority in sepsis, so efforts to wean septic patients from mechanical ventilation halt until sepsis is resolving. Additional respiratory support may be needed during sepsis. Although cool and clammy skin is present in other early shock states, the patient in early septic shock may feel warm and flushed because of a hyperdynamic state.

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which common complication? A. Dehydration B. Paralytic ileus C. Atrial dysrhythmias D. Acute respiratory distress syndrome

ANS: C Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days after CABG surgery. Although the other complications could occur, they are not common complications.

Diltiazem (Cardizem) is prescribed for a patient with newly diagnosed Prinzmetal's (variant) angina. Which action of diltiazem is accurate for the nurse to include in the teaching plan? A. Reduces heart palpitations. B. Prevents coronary artery plaque. C. Decreases coronary artery spasms. D. Increases contractile force of the heart.

ANS: C Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and -adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand.

To evaluate the effectiveness of the pantoprazole (Protonix) given to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Ask the patient about nausea. c. Check stools for occult blood. d. Palpate for abdominal tenderness.

ANS: C Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration.

A client has received thrombolytic therapy after having a myocardial infarction. Which clinical manifestation would indicate to you that reperfusion has been successful? a. ST-segment depression b. Cessation of diaphoresis c. Sudden onset of pleuritic chest pain d. The onset of ventricular dysrhythmias

ANS: D d. The onset of ventricular dysrhythmias

IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. Which reassessment finding during the first hours of administration indicates that the nurse should decrease the rate of nitroprusside infusion? a. Ventricular ectopy b. Dry, hacking cough c. Systolic BP below 90 mm Hg d. Heart rate below 50 beats/min

ANS: C Sodium nitroprusside is a potent vasodilator and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.

The nurse in the recovery room assesses the right femoral artery puncture site after the patient had a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? A. Palpate the insertion site for induration. B. Assess peripheral pulses in the right leg. C. Inspect the patient's right side and back. D. Compare the color of the left and right legs.

ANS: C The best method to determine that the right femoral artery is intact after inspection of the insertion site is to logroll the patient to inspect the right side and back for retroperitoneal bleeding. The artery can be leaking, and blood is drawn into the tissues by gravity. The peripheral pulses, color, and sensation of the right leg will be assessed per agency protocol.

A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when scheduling this medication? A. Administer the medication at the patient's usual bedtime. B. Have the patient take the colesevelam 1 hour before breakfast. C. Give the patient's other medications 2 hours after colesevelam. D. Have the patient take the dose at the same time as the prescribed aspirin.

ANS: C The bile acid sequestrants interfere with the absorption of many other drugs and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. For maximum effect, colesevelam should be administered with meals.

When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing? a. Lactated Ringer's b. 5% dextrose in water c. 0.9% sodium chloride d. 0.45% sodium chloride

ANS: C The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. It is also used to flush the blood tubing after the infusion is complete to ensure the patient receives blood that is left in the tubing when the bag is empty. Dextrose and lactated Ringer's solutions cannot be used with blood because they will cause RBC hemolysis.

The nurse is administering a thrombolytic agent to a patient with an acute myocardial infarction. What patient data indicates that the nurse should stop the drug infusion? A. Bleeding from the gums B. An increase in blood pressure C. Decreased level of consciousness D. A nonsustained episode of ventricular tachycardia

ANS: C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action? a. The patient's heart rate is 58 beats/min. b. The patient's extremities are warm and dry. c. The patient's IV infusion site is cool and pale. d. The patient's urine output is 28 mL over the past hour.

ANS: C The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the drug into a central line. An apical pulse of 58 beats/min is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.

The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? A. The troponin level is elevated. B. The patient denies having a heart attack. C. Bilateral crackles in the mid-lower lobes. D. Occasional premature atrial contractions (PACs).

ANS: C The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.

While admitting an 82-yr-old patient with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." What should the nurse include in the discharge plan? a. Consult with a psychologist. b. Transfer to a long-term care facility. c. Referral to a home health care agency. d. Arrangements for around-the-clock care.

ANS: C The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as a psychologist consult, long-term care, or around-the-clock home care.

A patient is admitted to the emergency department (ED) in shock of unknown etiology. What should be the nurse's first action? a. Obtain the blood pressure. b. Check the level of orientation. c. Administer supplemental oxygen. d. Obtain a 12-lead electrocardiogram.

ANS: C The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be done as rapidly as possible after providing O2.

While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate? a. Decreased fluid volume b. Jugular vein atherosclerosis c. Increased right atrial pressure d. Incompetent jugular vein valves

ANS: C The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Physical assessment: petechiae noted on chest and legs, crackles heard bilaterally in lung bases, no redness or swelling at central line IV site. Laboratory data: BUN 34 mg/dL, Hct 30%, Platelets 50,000 /uL Vital signs: Temperature 100 F, Pulse 102/min, Respirations 26/min, BP 110/60 mm Hg, O2 Sat 93% on 2 L O2 via NC a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate

ANS: C The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will be discussed with the health care provider but does not show that the patient's condition is deteriorating or that a change in therapy is needed immediately.

A patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first? a. Review urinary output for the previous 24 hours. b. Restrict the patient's oral fluid intake to 500 mL/day. c. Assist the patient to a sitting position with arms on the overbed table. d. Teach the patient to use pursed-lip breathing until the dyspnea subsides.

ANS: C The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect.

The nurse reviews information shown in the accompanying figure from the medical records of a 43-year-old patient. Which risk factor modification for coronary artery disease should the nurse include in patient teaching? History: Father died of MI at age 65. Quit smoking 2 years ago. Works full time outside as a landscaper/gardener. Physical Assessment/VS: Waist circumference 34 in (86 cm). BMI 22.5 kg/m2. Pulse 78. Blood pressure 136/80 mm Hg. Diagnostic testing: Total cholesterol 190 mg/dL. HDL 35 mg/dL/ LDL 165 mg/dL. Triglycerides 142 mg/dL. A. Importance of daily physical activity B. Effect of weight loss on blood pressure C. Dietary changes to improve lipid levels D. Cardiac risk associated with previous tobacco use

ANS: C The patient has an elevated low-density lipoprotein cholesterol and low high-density lipoprotein cholesterol, which will increase the risk of coronary artery disease. The patient's waist circumference and body mass index indicate an appropriate body weight. The risk for coronary artery disease a year after quitting smoking is the same as a nonsmoker. The patient's occupation indicates that daily activity is at the levels suggested by national guidelines.

Which electrocardiographic (ECG) change by a patient with chest pain is most important for the nurse to report rapidly to the health care provider? A. Inverted P wave B. Sinus tachycardia C. ST-segment elevation D. First-degree atrioventricular block

ANS: C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction. Immediate therapy with percutaneous coronary intervention or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy but not as rapidly.

A patient with acute coronary syndrome has returned to the coronary care unit after having angioplasty with stent placement. Which assessment data indicate the need for immediate action by the nurse? A. Report of chest pain B. Heart rate 102 beats/min C. Pedal pulses 1+ bilaterally D. Blood pressure 103/54 mm Hg

ANS: C The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.

Which of the following clinical manifestations in a client taking a nonselective beta-blocking agent should the nurse explore as a complication of drug therapy? a. Headache b. Postural hypotension c. Nonproductive cough d. Wheezing

ANS: D d. Wheezing

A patient is taking a potassium-wasting diuretic for treatment of HF. The nurse will teach the patient to report symptoms of adverse effects such as a. personality changes b. frequent loose stools c. facial muscle spasms d. generalized weakness

ANS: D d. generalized weakness

Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to avoid an error during this procedure? a. Add the blood transfusion as a secondary line to the existing IV. b. Stay with the patient for 60 minutes after starting the transfusion. c. Check the identifying information on the unit of blood against the patient's ID bracelet. d. Prime new primary IV tubing with lactated Ringer's solution to use for the transfusion.

ANS: C The patient's identifying information (name, date of birth, medical record number) on the ID bracelet should exactly match the information on the blood bank tag that has been placed on the unit of blood. If any information does not match, the transfusions should not be hung because of possible error and risk to the patient. The transfusion is hung on blood transfusion tubing, not a secondary line, and cannot be hung with lactated Ringer's solution because it will cause RBC hemolysis. Usually, the patient will need continuous monitoring for 15 minutes after the transfusion is started, as this is the time most transfusion reactions occur. Then the patient should be monitored every 30 to 60 minutes during the administration.

A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom? A. Assess both feet for pedal edema. B. Palpate the radial pulses bilaterally. C. Auscultate for a pericardial friction rub. D. Check the heart monitor for dysrhythmias.

ANS: C The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms.

A patient who has chest pain is admitted to the emergency department (ED), and all of the following items are prescribed. Which one should the nurse arrange to be completed first? A. Chest x-ray B. Troponin level C. Electrocardiogram (ECG) D. Insertion of a peripheral IV

ANS: C The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that the appropriate therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction. Peripheral access will be needed but not before the ECG.

A patient with diabetes mellitus and chronic stable angina has a new order for captopril. What should the nurse teach this patient about the primary purpose of captopril? A. Decreases the heart rate. B. Controls blood glucose levels. C. Prevents changes in heart muscle. D. Reduces the frequency of chest pain.

ANS: C The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate.

A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse take first? a. Auscultate the abdomen. b. Check the capillary refill. c. Auscultate the breath sounds. d. Ask about the patient's allergies.

ANS: C This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) may be occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? A. "Do you have any allergies?" B. "Do you take aspirin daily?" C. "What time did your pain begin?" D. "Can you rate the pain on a 0 to 10 scale?"

ANS: C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information is not a factor in the decision about thrombolytic therapy.

In caring for the patient with angina, the patient said, "While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, then the pain went away." What further assessment data should the nurse obtain from the patient? A. "What precipitated the pain?" B. "Has the pain changed this time?" C. "In what areas did you feel this pain?" D. "What is your pain level on a 0 to 10 scale?"

ANS: C Using PQRST, the assessment data not volunteered by the patient is the radiation of pain, the area the patient felt the pain, and if it radiated. The precipitating event was going to the bathroom and having a bowel movement. The quality of the pain was "like before I was admitted," although a more specific description may be helpful. Severity of the pain was the "worst chest pain ever," although an actual number may be needed. Timing is supplied by the patient describing when the pain occurred and that he had previously had this pain.

After a patient who has septic shock receives 2 L of normal saline intravenously, the central venous pressure is 10 mm Hg and the blood pressure is 82/40 mm Hg. What medication should the nurse anticipate? a. Furosemide b. Nitroglycerin c. Norepinephrine d. Sodium nitroprusside

ANS: C When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

The nurse is caring for a patient with microcytic, hypochromic anemia. What teaching should the nurse provide about medication therapy? a. Take enteric-coated iron with each meal. b. Take cobalamin with green leafy vegetables. c. Take the iron with orange juice 1 hour before meals. d. Decrease the intake of the antiseizure medications to improve.

ANS: C With microcytic, hypochromic anemia may be caused by iron, vitamin B6, or copper deficiency; thalassemia; or lead poisoning. The iron prescribed should be taken with orange juice 1 hour before meals as it is best absorbed in an acid environment. Megaloblastic anemias occur with cobalamin (vitamin B12) and folic acid deficiencies. Vitamin B12 may help red blood cell (RBC) maturation if the patient has the intrinsic factor in the stomach. Green leafy vegetables provide folic acid for RBC maturation. Antiseizure drugs may contribute to aplastic anemia or folic acid deficiency, but the patient should not stop taking the medications. The health care provider will prescribe changes in medications.

When teaching a patient with heart failure on a 2000-mg sodium diet, which foods should the nurse recommend limiting? a. Chicken and eggs b. Canned and frozen fruits c. Yogurt and milk products d. Fresh or frozen vegetables

ANS: C Yogurt and milk products (e.g., cheese) naturally contain a significant amount of sodium, and the intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. The other foods listed have minimal levels of sodium and can be eaten without restriction.

A patient's BP is 98/52 and AP is 116 and irregular. The cardiac monitor shows sinus tachycardia, rate 110-120, with frequent multifocal PVCs. The nurse calls the HCP and receives these orders. Which one will the nurse implement first? a. Obtain serum digoxin level b. Give furosemide 100 mg IV c. Check blood potassium level d. Insert #16 French foley catheter

ANS: C c. Check blood potassium level Low K can lead to dysrhythmias

An 82-year-old client is admitted with a suspected myocardial infarction. What specific clinical manifestation of myocardial infarction would you expect to see in an older adult? a. Exophthalmos b. Posterior wall chest pain c. Disorientation and confusion d. Numbness and tingling of the arm

ANS: C c. Disorientation and confusion

By what pathophysiologic processes does atherosclerosis contribute to the development of coronary artery disease (CAD)? a. Atherosclerotic plaques cause spasm and subsequent narrowing of the coronary vessels. b. Coronary vessels become inflamed and injured as a result of excess cholesterol and triglycerides. c. Macrophages and T cells form a connective tissue matrix in the vessel intima where lipids accumulate. d. Atherosclerosis causes coronary vessels to become stiff, limiting their ability to respond to increases in blood flow.

ANS: C c. Macrophages and T cells form a connective tissue matrix in the vessel intima where lipids accumulate.

When reading the chart for a patient with COPD, the nurse notes that the patient has cor pulmonale. To assess for cor pulmonale, the nurse will monitor the patient for a. elevated temperature b. complaints of chest pain c. jugular vein distension d. clubbing of the fingers

ANS: C c. jugular vein distension

A patient who has been receiving diuretic therapy is admitted to the ED with a serum potassium level of 3.1 mEq/L. Of the following medications that the patient has been taking at home, the nurse will be most concerned about a. metoprolol (Lopressor) 12.5 mg orally daily b. lantus insulin 24 U subcutaneously every evening c. oral digoxin (Lanoxin) 0.125 mg daily. d. ibuprofen (Motrin) 400 mg every 6 hours.

ANS: C c. oral digoxin (Lanoxin) 0.125 mg daily.

A ER nurse assesses clients with chest pain. Which client should the nurse plan to assess first? a. a male client who reports pain on expiration and when he sits up b. a female who reports pain that radiates to her abdomen c. a female who describes her pain as dull d. a male who reports pain on the entire anterior chest

ANS: D

A HH nurse is visiting a client post anginal admission who has been started on a beta blocker. Which of the answer indicates that the drug is having the intended effect? a. no crackles with breath sounds and oxygen saturation > 94% b. urine output 40-60 mL/hr c. no hand tremors or incoordination d. no reports of chest pain

ANS: D

After successful digitalization, a patient is to begin oral maintenance of digoxin (Lanoxin) and furosemide (Lasix) for control of congestive heart failure. To prevent digitalis toxicity, the nurse understands that it is most important to monitor the patient's a. body weight b. liver function c. blood pressure d. serum potassium

ANS: D

The HH nurse visits a client two weeks post hospitalization for angina. The patient will use a nitro patch at home. The nurse would assess the patient's knowledge about a. the SL administration of NTG b. assessing respiration prior to taking the drug c. frequency of angina d. orthostatic hypotension

ANS: D

The nurse identifies the collaborative problem of potential complication, pulmonary edema for a patient in acute congestive heart failure. To prevent severe symptoms, an early finding of this problem the nurse should monitor for is a. bradycardia b. pink, frothy sputum c. decreased urinary output d. restlessness and agitation

ANS: D

The nurse monitors a patient receiving IV furosemide (Lasix) and enalapril (Vasotec) 5 mg po bid for an acute exacerbation of congestive heart failure. The nurse determines that the treatment is effective upon finding a. weight loss of 2 pounds b. an increase in urinary output c. a decrease in systolic blood pressure d. fewer crackles upon lung auscultation

ANS: D

Which of the following conditions causes the chest pain seen with angina? a. increased preload b. decreased afterload c. decreased contractility d. decreased oxygen supply to the myocardium

ANS: D

Which of the following is most accurate? a. a reliable indicator of any myocardial necrosis that has occured is CK b. serum cardiac marker will be inconclusive in determining myocardial injury that is several days old c.myoglobin levels will be needed to confirm myocardial damage since it is one of the first cardiac enzymes to be elevated after a MI d. myocardial damage occurring several days earlier can be validated best by the troponin level

ANS: D

The emergency department (ED) nurse receives report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. What should the nurse obtain in preparation for the patient's arrival? a. A dopamine infusion b. A hypothermia blanket c. Lactated Ringer's solution d. Two 16-gauge IV catheters

ANS: D A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large-bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and would not be prescribed until the patient has been assessed for liver abnormalities. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. Patients in shock need to be kept warm not cool.

The nurse is assisting in the care of several patients in the critical care unit. Which patient is most at risk for developing multiple organ dysfunction syndrome (MODS)? a. A 22-yr-old patient with systemic lupus erythematosus admitted with a pelvic fracture b. A 48-yr-old patient with lung cancer admitted for syndrome of inappropriate antidiuretic hormone and hyponatremia c. A 65-yr-old patient with coronary artery disease, dyslipidemia, and primary hypertension admitted for unstable angina d. A 82-yr-old patient with type 2 diabetes and chronic kidney disease admitted for peritonitis from a peritoneal dialysis catheter infection

ANS: D A patient with peritonitis is at high risk for developing sepsis. In addition, a patient with diabetes is at high risk for infections and impaired healing. Sepsis and septic shock are the most common causes of MODS. Those at greatest risk for developing MODS are older adults and persons with significant tissue injury or preexisting disease. MODS can be initiated by any severe injury or disease process that activates a massive systemic inflammatory response.

Following an acute myocardial infarction, a previously healthy 63-yr-old develops heart failure. What medication topic should the nurse anticipate including in discharge teaching? a. B-Adrenergic blockers b. Calcium channel blockers c. Digitalis and potassium therapy regimen d. Angiotensin-converting enzyme (ACE) inhibitors

ANS: D ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other drugs such as ACE-inhibitors, diuretics, and B-adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The B-adrenergic blockers are not used as initial therapy for new onset heart failure.

After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first? A. A 39-year-old patient with pericarditis who is complaining of sharp, stabbing chest pain. B. A 56-year-old patient with variant angina who is scheduled to receive nifedipine (Procardia). C. A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge. D. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI).

ANS: D After PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient's blood pressure, pulses, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? a. captopril (Capoten) 25 mg b. furosemide (Lasix) 60 mg c. digoxin (Lanoxin) 0.125 mg d. carvedilol (Coreg) 3.125 mg

ANS: D Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other drugs are appropriate for the patient with ADHF.

Which statement made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? A. "I will switch from whole milk to 1% milk." B. "I like salmon and I will plan to eat it more often." C. "I can have a glass of wine with dinner if I want one." D. "I will miss being able to eat peanut butter sandwiches."

ANS: D Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monounsaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

A patient experienced sudden cardiac death (SCD) and survived. Which treatment should the nurse expect to be implemented to prevent an SCD recurrence at home? A. External cardiac pacemaker B. An electrophysiologic study (EPS) C. Medications to prevent dysrhythmias D. Implantable cardioverter-defibrillator (ICD)

ANS: D An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used but are not the best prevention of SCD.

Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation

ANS: D Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. What data would indicate to the nurse that the drug is effective? A. Decreased blood pressure and heart rate B. Improvement in the strength of the distal pulses C. Fewer complaints of having cold hands and feet D. Participation in daily activities without chest pain

ANS: D Because the drug is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The non cardioselective B-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to contact the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient's heart rate is 110 beats/min. c. The patient's peripheral pulses are weak. d. The patient reports diffuse chest pressure.

ANS: D Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion and cause chest pain or pressure. Low urine output, weal pulses, and tachycardia are consistent with the patient's diagnosis. They and should be reported to the health care provider but do not require an immediate need for a change in therapy.

A patient is scheduled for a heart transplant. What is a major cause of death beyond the first year after a heart transplant? a. Infection b. Acute rejection c. Immunosuppression d. Cardiac vasculopathy

ANS: D Beyond the first year after a heart transplant, cancer (especially lymphoma) and cardiac vasculopathy (accelerated coronary artery disease) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient's risk of an infection.

The nurse teaches a black man with sickle cell disease about symptom management and prevention of sickle cell crisis. The nurse determines further teaching is necessary if the patient makes which statement? a. "When I take a vacation, I should not go to the mountains." b. "I should avoid being with anyone who has a respiratory infection." c. "I may have severe pain during a crisis and need opioid analgesics." d. "When my vision is blurred, I will close my eyes and rest for an hour."

ANS: D Blurred vision should be reported immediately and may indicate a detached retina or retinopathy. Hypoxia (at high altitudes) and infection are common causes of a sickle cell crisis. Severe pain may occur during a sickle cell crisis, and narcotic analgesics are indicated for pain management.

Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina? A. "The pain wakes me up at night." B. "The pain is level 3 to 5 (0 to 10 scale)." C. "The pain has gotten worse over the last week." D. "The pain goes away after a nitroglycerin tablet."

ANS: D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

The nurse teaches a patient with high cholesterol about natural lipid-lowering therapies. The nurse determines further teaching is necessary when the patient makes which statement? A. "Omega-3 fatty acids are helpful in reducing triglyceride levels." B. "I should check with my physician before I start taking any herbal products." C. "Herbal products do not go through as extensive testing as prescription drugs do." D. "I will take garlic instead of my prescription medication to reduce my cholesterol."

ANS: D Current evidence does not support using garlic in the treatment of elevated cholesterol. Strong evidence supports the use of omega-3 fatty acids for reduction of triglyceride levels. Many herbal products are not standardized, and effects are not predictable. Patients should consult with their health care provider before starting herbal or natural therapies.

A male patient with coronary artery disease (CAD) has a low-density lipoprotein (LDL) cholesterol of 98 mg/dL and high-density lipoprotein (HDL) cholesterol of 47 mg/dL. What information should the nurse include in patient teaching? A. Consume a diet low in fats. B. Reduce total caloric intake. C. Increase intake of olive oil. D. The lipid levels are normal.

ANS: D For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40mg/dL. His normal lipid levels should be included in the patient teaching and encourage him to continue taking care of himself. Assessing his need for teaching related to diet should also be done.

A female patient with type 1 diabetes has chronic stable angina controlled with rest. She states that over the past few months, she has required increasing amounts of insulin. What goal should the nurse use in planning care to prevent cardiovascular disease progression? A. Exercise almost every day. B. Avoid saturated fat intake. C. Limit calories to daily limit. D. Keep Hgb A1C less than 7%.

ANS: D If the Hgb A1C is kept below 7%, this means that the patient has had good control of her blood glucose over the past 3 months. The patient indicates that increasing amounts of insulin are being required to control her blood glucose. This patient may not be adhering to the dietary guidelines or therapeutic regimen, so teaching about how to maintain diet, exercise, and medications to maintain stable blood glucose levels will be needed to achieve this goal.

The patient is being dismissed from the hospital after acute coronary syndrome (ACS) and will be attending rehabilitation. What information would be taught in the early recovery phase of rehabilitation? A. Therapeutic lifestyle changes should become lifelong habits. B. Physical activity is always started in the hospital and continued at home. C. Attention will focus on managing chest pain, anxiety, dysrhythmias, and other complications. D. Activity level is gradually increased under cardiac rehabilitation team supervision and monitoring.

ANS: D In the early recovery phase after the patient is dismissed from the hospital, the activity level is gradually increased under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery, activity is dependent on the severity of the angina or myocardial infarction, and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that physical activity be initiated at home, but this is not always done.

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? A. Chronic stable angina B. Left-sided heart failure C. Coronary artery disease D. Acute myocardial infarction

ANS: D PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and coronary artery disease are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure.

After coronary artery bypass graft surgery, a patient has postoperative bleeding that requires returning to surgery for repair. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient parameter is the most important for planning nursing care? a. Cardiac index (CI) of 5 L/min/m2 b. Central venous pressure of 8 mm Hg c. Mean arterial pressure (MAP) of 86 mm Hg d. Pulmonary artery pressure (PAP) of 28/14 mm Hg

ANS: D Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be a result of the MI. The CI, CVP, and MAP readings are normal.

The nurse is caring for a patient in cardiogenic shock after an acute myocardial infarction. Which assessment findings would be most concerning? a. Restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds b. Agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL c. Mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin d. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding

ANS: D Severe hypoxemia, lactic acidosis, and bleeding are manifestations of the irreversible state of shock. Recovery from this stage is not likely because of multiple organ system failure. Restlessness, tachycardia, and hypoactive bowel sounds are manifestations that occur during the compensatory stage of shock. Decreased mean arterial pressure, jaundice, cold and clammy skin, agitation, tachypnea, and increased serum creatinine are manifestations of the progressive stage of shock.

Which statement by a patient with newly diagnosed heart failure indicates to the nurse that teaching was effective? a. "I will take furosemide (Lasix) every day just before bedtime." b. "I will use the nitroglycerin patch whenever I have chest pain." c. "I will use an additional pillow if I am short of breath at night." d. "I will call the clinic if my weight goes up 3 pounds in a week."

ANS: D Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 lb in 2 days or 3 to 5 lb in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as needed" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops rather than just compensating by further elevating the head of the bed.

A patient with a long-standing history of heart failure recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? a. Taper the patient off his current medications. b. Continue education for the patient and his family. c. Pursue experimental therapies or surgical options. d. Choose interventions to promote comfort and prevent suffering.

ANS: D The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated. Experimental therapies and surgeries are not used in the care of hospice patients.

Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective? A. "I can expect nausea as a side effect of nitroglycerin." B. "I should only take nitroglycerin when I have chest pain." C. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart." D. "I will call an ambulance if I have pain after taking 3 nitroglycerin 5 minutes apart."

ANS: D The emergency response system (ERS) should be activated when chest pain or other symptoms are not completely relieved after three sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which patient problem is the priority? A. Anxiety B. Acute pain C. Stress management D. Decreased cardiac output

ANS: D The hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.

A patient with a massive gastrointestinal bleed has developed hypovolemic shock. What is the priority nursing diagnosis? a. Anxiety b. Acute pain c. Impaired tissue integrity d. Ineffective tissue perfusion

ANS: D The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses.

An asymptomatic patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before dangling the patient on the bedside, what should the nurse assess first? a. Urine output b. Heart rhythm c. Breath sounds d. Blood pressure

ANS: D The nurse should evaluate the blood pressure before dangling the patient on the bedside because the blood pressure can decrease as blood pools in the periphery and preload decreases. If the patient's blood pressure is low or marginal, the nurse should put the patient in the semi-Fowler's position and use other measures to improve gas exchange.

An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? a. 2+ bilateral pedal edema b. Heart rate of 52 beats/min c. Report of increased fatigue d. Blood pressure (BP) of 88/42 mm Hg

ANS: D The patient's BP indicates that the dose of metoprolol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of -adrenergic blockade, though it may need to be monitored. -Adrenergic blockade initially will worsen symptoms of heart failure in many patients and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.

What laboratory finding is consistent with cardiogenic shock? a. Decreased liver enzymes b. Increased white blood cells c. Decreased red blood cells, hemoglobin, and hematocrit d. Increased blood urea nitrogen (BUN) and creatinine levels

ANS: D The renal hypoperfusion that accompanies cardiogenic shock results in increased BUN and creatinine levels. Impaired perfusion of the liver results in increased liver enzymes, but white blood cell levels do not typically increase in cardiogenic shock. Red blood cell indices are typically normal because of relative hypovolemia.

A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test is most specific for the nurse to monitor in determining whether the patient has had an AMI? A. Myoglobin B. Homocysteine C. C-reactive protein D. Cardiac-specific troponin

ANS: D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease but are not helpful in determining whether an acute MI is in progress.

Which intervention may decrease the rate at which erythrocytes are produced? a. Multiple platelet transfusions b. Subcutaneous administration of erythropoietin (Epogen, Procrit) c. Repeated (daily) venous blood sampling for laboratory testing d. Continuous administration of oxygen by nasal cannula or mask

ANS: D d. Continuous administration of oxygen by nasal cannula or mask

A patient's BP is 98/52 and AP is 116 and irregular. The cardiac monitor shows sinus tachycardia, rate 110-120, with frequent multifocal PVCs. The nurse calls the HCP and receives these orders. Which of these orders can be delegated by the RN to the LPN/LVN? a. Obtain serum digoxin level b. Give furosemide 100 mg IV c. Check blood potassium level d. Insert #16 French Foley catheter

ANS: D d. Insert #16 French Foley catheter

A nurse assesses a client after a cardiac cath via the left femoral artery. The nurse palpates a weak left pedal pulse. What should the nurse do next? a. Elevate the leg and apply pressure to the catheterization site b. Increase the flow rate of the IV fluids c. Use a doppler to confirm the presence of the pulse d. Document the finding as "left pedal pulse of +1/4" e. Evaluate the color and temperature of the left leg

ANS: E

The health care provider prescribes the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Obtain blood and urine cultures. b. Give vancomycin by IV infusion. c. Start norepinephrine 0.5 mcg/min. d. Infuse normal saline 2000 mL over 30 minutes. e. Administer oxygen to keep O2 saturation above 95%.

ANS: E, D, C, A, B The initial action for this hypotensive and hypoxemic patient should be to improve the O2 saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before giving antibiotics.

When caring for a patient with thrombocytopenia, the nurse instructs the patient to a. dab his or her nose instead of blowing b. be careful when shaving with a safety razor c. continue with physical activities to stimulate thrombopoiesis d. avoid aspirin because it may mask the fever that occurs with thrombocytopenia

ANS: a a. dab his or her nose instead of blowing

A complication of the hyperviscosity of polycythemia is A. thrombosis. B. cardiomyopathy. C. pulmonary edema. D. disseminated intravascular coagulation (DIC).

ANS: a a. thrombosis

A patient with chronic heart failure and atrial fibrillation is treated with low-dose digitalis and a loop diuretic. What does the nurse need to do to prevent complications of this drug combination? (Select all that apply) a. Monitor serum potassium levels b. Teach the patient how to take a pulse rate. c. Withhold digitalis if pulse rate is irregular. d. Keep an accurate measure of intake and output. e. Teach the patient about dietary potassium restrictions.

ANS: a, b a. Monitor serum potassium levels b. Teach the patient how to take a pulse rate.

The nursing management of a patient in sickle cell crisis includes (select all that apply) a. monitoring CBC b. optimal pain management and O2 therapy c. blood transfusions if needed and iron chelation d. rest as needed and deep vein thrombosis prophylaxis e. administration of IV iron and diet high in iron content

ANS: a, b, c, d a. monitoring CBC b. optimal pain management and O2 therapy c. blood transfusions if needed and iron chelation d. rest as needed and deep vein thrombosis prophylaxis

Priority nursing interventions when caring for a hospitalized patient with a new onset temperature of 102.2 F and severe neutropenia include (select all that apply) a. starting the prescribed antibiotic STAT b. drawing peripheral and central line blood cultures c. ongoing monitoring of the patient's vital signs for septic shock d. taking a full set of vital signs and notifying the physician immediately e. administering transfusions of WBCs treated to decrease immunogenicity

ANS: a, b, c, d a. starting the prescribed antibiotic STAT b. drawing peripheral and central line blood cultures c. ongoing monitoring of the patient's vital signs for septic shock d. taking a full set of vital signs and notifying the physician immediately

Which statements accurately describe heart failure with preserved ejection fraction (HFpEF)? Select all that apply. a. Uncontrolled hypertension is the primary cause. b. Left ventricular ejection fraction may be within normal limits. c. The pathophysiology involves ventricular relaxation and filling. d. Multiple evidence-based therapies have been shown to decrease mortality. e. Therapies focus on symptom control and treatment of underlying conditions.

ANS: a, b, c, e a. Uncontrolled hypertension is the primary cause. b. Left ventricular ejection fraction may be within normal limits. c. The pathophysiology involves ventricular relaxation and filling. e. Therapies focus on symptom control and treatment of underlying conditions.

Treatment modalities for the management of cardiogenic shock include (select all that apply) a. dobutamine to increase myocardial contractility b. vasopressors to increase systemic vascular resistance c. circulatory assist devices such as an intraaortic balloon pump d. corticosteroids to stabilize the cell wall in the infarcted myocardium e. trendelenburg positioning to facilitate venous return and increase preload

ANS: a, c a. dobutamine to increase myocardial contractility c. circulatory assist devices such as an intraaortic balloon pump

Nursing interventions for a patient with severe anemia related to peptic ulcer disease include (Select all that apply) a. instructions for high-iron diet b. taking vital signs every 8 hours c. monitoring stools for occult blood d. teaching self-injection of erythropoietin e. administration of cobalamin (vitamin B12) injections

ANS: a, c a. instructions for high-iron diet c. monitoring stools for occult blood

When obtaining assessment data from a patient with a microcytic, hypochromic anemia, the nurse would ask the patient about a. folic acid intake b. dietary intake of iron c. a history of gastric surgery d. a history of sickle cell anemia

ANS: b b. dietary intake of iron

When reviewing a patient's hematologic laboratory values after a splenectomy, the nurse would expect to find a. RBC abnormalities b. increased WBC count c. decreased hemoglobin d. decreased platelet count

ANS: b b. increased WBC count

A 78-year-old man with a history of diabetes has confusion and temperature of 104 F. There is a wound on his right heel with purulent drainage. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/min; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of a. sepsis b. septic shock c. multiple organ dysfunction syndrome d. systemic inflammatory response syndrome

ANS: b b. septic shock

In teaching a patient about coronary artery disease, the nurse explains that the changes that occur in this disorder include (select all that apply) a. diffuse involvement of plaque formation in coronary veins b. abnormal levels of cholesterol, especially low-density lipoproteins c. accumulation of lipid and fibrous tissue within the coronary arteries d. development of angina due to a decreased blood supply to the heart muscle e. chronic vasoconstriction of coronary arteries leading to permanent vasospasm

ANS: b, c, d

Patients are at risk for which complications in the first year after heart transplantation? (Select all that apply) a. Cancer b. Infection c. Rejection d. Vasculopathy e. Sudden cardiac death

ANS: b, c, e b. Infection c. Rejection e. Sudden cardiac death

After a bone marrow aspiration, the client has bruising at the site (left iliac chest). What is your best action? a. Document the finding as the only action. b. Position the client on his/her right side. c. Apply an ice pack to the site. d. Notify the physician.

ANS: c c. Apply an ice pack to the site.

DIC is a disorder in which a. the coagulation pathway is genetically altered, leading to a thrombus formation in all major blood vessels. b. an underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic episodes and infarcts. c. a disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage. d. an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature.

ANS: c c. a disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage.

In a severely anemic patient, the nurse would expect to find a. cyanosis and cardiomegaly b. pulmonary edema and fibrosis c. dyspnea at rest and tachycardia d. ventricular dysrhythmias and wheezing

ANS: c c. dyspnea at rest and tachycardia

A patient with multiple myeloma becomes confused and lethargic. The nurse would expect that these clinical manifestations may be explained by diagnostic results that indicate a. hyperkalemia b. hyperuricemia c. hypercalcemia d. CNS myeloma

ANS: c c. hypercalcemia

The nurse is aware that a major difference between Hodgkin's lymphoma and non-Hodgkin's lymphoma is that a. Hodgkin's lymphoma occurs only in young adults b. Hodgkin's lymphoma is considered potentially curable c. non-Hodgkin's lymphoma can manifest in multiple areas d. non-Hodgkin's lymphoma is treated only with radiation therapy

ANS: c c. non-Hodgkin's lymphoma can manifest in multiple areas

The nurse is caring for a patient with acute decompensated heart failure who is receiving IV dobutamine. Why would this drug be prescribed? (Select all that apply) a. It dilates renal blood vessels. b. It will increase the heart rate. c. Heart contractility will improve. d. Dobutamine is a selective B-agonist. e. It increases systemic vascular resistance.

ANS: c, d c. Heart contractility will improve. d. Dobutamine is a selective B-agonist.

What compensatory mechanism involved in both chronic heart failure and acute decompensated heart failure leads to fluid retention and edema? a. Ventricular dilation b. Ventricular hypertrophy c. Increased systemic blood pressure d. Renin-angiotensin-aldosterone activation

ANS: d d. Renin-angiotensin-aldosterone activation

The most common type of leukemia in adults in western countries is a. acute myelocytic leukemia b. acute lymphocytic leukemia c. chronic myelocytic leukemia d. chronic lymphocytic leukemia

ANS: d d. chronic lymphocytic leukemia

Because myelodysplastic syndrome arises from the pluripotent hematopoietic stem cell in the bone marrow, laboratory results the nurse would expect to find include a(n) a. excess of T cells b. excess of platelets c. deficiency of granulocytes d. deficiency of all cellular blood components

ANS: d d. deficiency of all cellular blood components

A barrier to hospice referrals for patients with stage D heart failure is a. family member refusal. b. scarcity of hospice facilities. c. history of pacemaker placement. d. difficulty in estimating prognosis.

ANS: d d. difficulty in estimating prognosis.

The nurse would expect that a patient with von Willebrand disease undergoing surgery would be treated with administration of vWF and a. thrombin b. factor VI c. factor VII d. factor VIII

ANS: d d. factor VIII

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are a. blood pressure, pulse, and respirations b. breath sounds, blood pressure, and body temperature c. pulse pressure, level of consciousness, and pupillary response d. level of consciousness, urine output, and skin color and temperature

ANS: d d. level of consciousness, urine output, and skin color and temperature

A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing a. a relative hypervolemia b. an absolute hypervolemia c. neurogenic shock from low blood flow d. neurogenic shock from massive vasodilation

ANS: d d. neurogenic shock from massive vasodilation

Multiple drugs are often used in combinations to treat leukemia and lymphoma because a. there are fewer toxic side effects b. the chance that one drug will be effective is increased c. the drugs are more effective without causing side effects d. the drugs work by different mechanisms to maximize killing of cancer cells

ANS: d d. the drugs work by different mechanisms to maximize killing of cancer cells

Complications of transfusions that can be decreased by using leukocyte depletion or reduction of RBC transfusion are a. chills and hemolysis b. leukostasis and neutrophilia c. fluid overload and pulmonary edema d. transmission of cytomegalovirus and fever

ANS: d d. transmission of cytomegalovirus and fever

Which patient is at greatest risk for sudden cardiac death? A. A 42-year-old white woman with hypertension and dyslipidemia B. A 52-year-old African American man with left ventricular failure C. A 62-year-old obese man with diabetes mellitus and high cholesterol D. A 72-year-old Native American woman with a family history of heart disease

B. A 52-year-old African American man with left ventricular failure. Patients with left ventricular dysfunction (ejection fraction < 30%) and ventricular dysrhythmias after MI are at greatest risk for sudden cardiac death (SCD). Other risk factors for SCD include (1) male gender (especially African American men), (2) family history of premature atherosclerosis, (3) tobacco use, (4) diabetes mellitus, (5) hypercholesterolemia, (6) hypertension, and (7) cardiomyopathy.

The patient comes to the ED with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerotic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? A. Unstable angina B. Acute coronary syndrome (ACS) C. ST-segment-elevation myocardial infarction (STEMI) D. Non-ST-segment-elevation myocardial infarction (NSTEMI)

B. Acute coronary syndrome (ACS) The pain with ACS is severe, prolonged, and not easy to relieve. ACS is associated with deterioration of a once-stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will be manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as a STEMI.

Questions from ch. 33, 66, 34, 30

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