exam 1 quizbank 4626

which assessment finding in a pt admitted with ADHF requires the most immediate action by the nurse? a) O2sat of 88% b) weight gain of 1 kg c) HR of 106 d) Urine output of 50 mL over 2 hours

a) O2sat of 88% (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 also indicate worsening heart failure and require nursing actions, but the low O2 saturation rate requires the most immediate nursing action)

the nurse is caring for a pt with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? a) obtain VS b) teach wound care c) assess pedal pulses d) check the wound site

a) obtain VS (Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions are also appropriate but can be done after determining that bleeding is not occurring)

after receiving information about four patients during change of shift report, which pt should the nurse assess first? a) pt with acute pericarditis who has a pericardial friction rub b) pt who has just returned to the unit after balloon valvuloplasty c) pt who has hypertrophic cardiomyopathy and a HR of 116 d) pt with a mitral valve replacement who has an anticoagulant scheduled

b) pt who has just returned to the unit after balloon valvuloplasty (The patient who has just arrived after balloon valvuloplasty will need assessment for complications such as bleeding and hypotension. The information about the other patients is consistent with their diagnoses and does not indicate any complications or need for urgent assessment or intervention)

a pt has a junctional escape rhythm on the monitor. The nurse will expect the pt to have a heart rate of: a) 15-20 bpm b) 20-40 bpm c) 40-60 bpm d) 60-100 bpm

c) 40-60 bpm (if the SA node fails to discharge, the AV node will automatically discharge at the normal rate of 40-60 bpm. The slower rates are typical of the bundle of His and Purkinje system and may be seen with failure of both the SA and AV node to discharge. The normal SA node rate is 60-100 bpm)

when caring for a pt with infective endocarditis of the tricuspid valve, the nurse should monitor the pt for the development of: a) flank pain b) splenomegaly c) SOB d) mental status changes

c) SOB (Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, changes in mental status, and splenomegaly would be associated with embolization from the left-sided valves)

which statement by a pt with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been effective? a) I will avoid taking aspirin or other antiinflammatory drugs b) I can restart my exercise program that includes hiking and biking c) I will need to limit my intake of salt and fluids even in hot weather d) I will take antibiotics before my teeth are cleaned at the dental office

d) I will take antibiotics before my teeth are cleaned at the dental office (Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use prophylactic antibiotics for any procedure that may cause bacteremia. The other statements indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt (unless ordered), aspirin, or nonsteroidal antiinflammatory drugs)

the nurse knows that discharge teaching about the management of a new permanent pacemaker has been most effective when the patient states: a) It will be several weeks before I can return to my usual activities b) I will avoid cooking with a microwave oven or being near one in use c) I will notify the airlines when I make a reservation that I have a pacemaker d) I won't lift the arm on the pacemaker side until I see the HCP

d) I won't lift the arm on the pacemaker side until I see the HCP (The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.)

a pt with rheumatic fever has a subcutaneous nodules, erythema marginatum, and polyarthritis. The pt reports that discomfort in the joints prevents favorite activities such as taking a daily walk and working on sewing projects. Based on these findings, which nursing diagnosis statement would be appropriate? a) activity intolerance r/t arthralgia b) anxiety r/t permanent joint fixation c) altered body image r/t polyarthritis d) social isolation r/t pain and swelling

a) activity intolerance r/t arthralgia (The patient's joint pain will lead to difficulty with activity. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes. This patient did not provide any data to support a diagnosis of social isolation, anxiety, or altered body image)

A 20 yo patient has a mandatory electrocardiogram before participating on a college soccer team and is found to have sinus bradycardia, rate 52. BP is 114/54, and the student denies any health problems. What action by the nurse is most appropriate? a) allow the student to participate on the soccer team b) refer the student to a cardiologist for further testing c) tell the student to stop playing Immediately if any dyspnea occurs d) obtain more detailed information about the student's family health hx

a) allow the student to participate on the soccer team (In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family's health history. Dyspnea during an aerobic activity such as soccer is normal)

A pt with dilated cardiomyopathy has new onset A fib that has been unresponsive to drug therapy for several days. Teaching for this p would include information about: a) anticoagulant therapy b) permanent pacemakers c) emergency cardioversion d) IV adenosine (Adenocard)

a) anticoagulant therapy (Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate.)

when planning care for a pt hospitalized with a streptococcal IE which intervention is most appropriate for the nurse to include? a) arrange for placement of a long-term IV catheter b) monitor labs for levels of streptococcal antibodies c) teach the importance of completing all oral antibiotics d) encourage the pt to begin regular aerobic exercise

a) arrange for placement of a long-term IV catheter (Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy)

two days after an acute MI, a pt complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first? a) auscultate the heart sounds b) check the pts temp c) give the PRN acetaminophen d) notify the pts HCP

a) auscultate the heart sounds (The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature and notifying the health care provider are also appropriate actions but would not be done before listening for a rub. Acetaminophen (Tylenol) is not very effective for pericarditis pain, and an analgesic would not be given before assessment of a new symptom)

an older pt with a hx of an AAA arrives at the ER with severe back pain and absent pedal pulses. Which action should the nurse take first? a) check the BP b) draw blood for laboratory testing c) assess for the presence of an abdominal bruit d) determine any family hx of heart disease

a) check the BP (Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions may also be done, but they will not provide information to determine what interventions are needed immediately)

a pt in the ICU with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been ordered for the pt. The nurse's priority action will be to: 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

a) give PRN IV morphine sulfate 4 mg (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)

After the nurse gives IV atropine to a pt with symptomatic type 1, second-degree AV block, which finding indicates that the drug has been effective? a) Increase in the pts heart rate b) increase in strength of peripheral pulses c) Decrease in premature atrial contractions d) Decrease in premature ventricular contractions

a) increase in the pts HR (Atropine will increase the heart rate and conduction through the AV node. Because the drug increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions.)

which action should the nurse include in the plan of care when caring for a pt admitted with ADHF who is receiving nesiritide (Natrecor)? a) monitor BP frequently b) encourage pt to ambulate in room c) titrate nesiritide slowly before stopping d) teach pt about home use of the drug

a) monitor BP frequently (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 and is used for ADHF but not in a home setting)

the nurse is caring for a pat immediately after repair of an AAA. On assessment, the pt has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a) notify the surgeon and anesthesiologist b) wrap both the legs in a warming blanket c) document the findings and recheck in 15 min d) compare findings to the preoperative assessment of the pulses

a) notify the surgeon and anesthesiologist (Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graft occlusion. These findings should be reported to the surgeon immediately because this is an emergency situation. Because pulses are marked before surgery, the nurse would know whether pulses were present before surgery before notifying the health care providers about the absent pulses. Because the patient's symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 15 minutes before taking action. A warming blanket will not improve the circulation to the patient's legs)

the nurse suspects cardiac tamponade in a pt who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should: a) subtract the diastolic blood pressure from the systolic blood pressure b) note when Korotkoff sounds are auscultated during both inspiration and expiration c) check the ECG for variations in rate during the respiratory cycle d) listen for a pericardial friction rub that persists when the patient is instructed to stop breathing

b) note when Korotkoff sounds are auscultated during both inspiration and expiration (Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus)

after receiving change of shift report, which pt admitted to the ER should the nurse assess first? a) 67 yo pt who has a gangrenous left foot ulcer with a weak pedal pulse b) 50 yo pt who is complaining of sudden sharp and severe upper back pain c) 39 yo pt who has right calf tenderness, redness, and swelling after a plane ride d) 58 yo pt who is taking anticoagulants for atrial fibrillation and has black stools

b) 50 yo pt who is complaining of sudden sharp and severe upper back pain (The patient's presentation of sudden sharp and severe upper back pain is consistent with dissecting thoracic aneurysm, which will require the most rapid intervention. The other patients also require rapid intervention but not before the patient with severe pain)

A patient has ST segment changes that suggest an acute inferior wall MI. Which lead would the the best for monitoring the patient? a) I b) II c) V2 d) V6

b) II (Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area)

during the assessment of a young adult pt with IE, the nurse would expect to find: a) substernal chest pressure b) a new regurgitant murmur c) a pruritic rash on the chest d) involuntary muscle movement

b) a new regurgitant murmur (New regurgitant murmurs occur in IE because vegetations on the valves prevent valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever)

Which nursing action can the registered nurse delegate to experienced unlicensed assistive personnel (UAP) working as telemetry technicians on the cardiac care unit? a) decide whether a pts HR of 116 requires urgent treatment b) observe heart rhythms for multiple pts who have telemetry monitoring c) monitor a pts LOC during synchronized cardioversion d) select the best lead for monitoring a pt admitted with acute coronary syndrome

b) observe heart rhythms for multiple pts who have telemetry monitoring (UAP serving as telemetry technicians can monitor heart rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice)

to assess the pt with pericarditis for evidence of a pericardial friction rub, the nurse should: a) listen for a rumbling, low-pitched, systolic murmur over the left anterior chest b) auscultate the diaphragm of the stethoscope on the lower left sternal border c) ask the pt to cough during auscultation to distinguish the sound from a pleural friction rub d) feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction

b) auscultate the diaphragm of the stethoscope on the lower left sternal border (Pericardial friction rubs are best heard with the diaphragm at the lower left sternal border. The nurse should ask the patient to hold his or her breath during auscultation to distinguish the sounds from a pleural friction rub. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation)

a patient has a sinus rhythm and a HR of 72 bpm. The nurse determines that the PR interval is 0.24 seconds. The most appropriate intervention by the nurse would be to: a) notify the HCP immediately b) document the finding and monitor the pt c) give atropine per agency dysrhythmia policy d) prepare the pt for temporary pacemaker insertion

b) document the finding and monitor the pt (first-degree AV block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the HCP about an asymptomatic rhythm is not necessary)

a pt is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the pt about the purpose of: a) blood cultures b) echocardiography c) cardiac catheterization d) 24 hr Holter monitor

b) echocardiography (Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac catheterization and 24-hour Holter monitor are not diagnostic procedures for pericarditis)

Which action should the nurse perform when preparing a pt with supraventricular tachycardia for cardioversion who is alert and has a BP of 110/66? a) turn the synchronizer to the "off" position b) give a sedative before cardioversion is implemented c) set the defibrillator/cardioverter energy to 360 joules d) provide assisted ventilations with a bag-valve mask device

b) give a sedative before cardioversion is implemented (When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient)

a pt with a hx of HTN treated with a diuretic and an ACE inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a BP of 238/118. Which question should the nurse ask to follow up on these findings? a) have you recently taken any antihistamines? b) have you consistently taken your medications? c) did you take any acetaminophen today? d) have there been recent stressful events in your life?

b) have you consistently taken your medications? (Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient)

the nurse is admitting a pt with possible rheumatic fever. Which question on the admission health hx focuses on a pertinent risk factor for rheumatic fever? a) do you use any illegal IV drugs? b) have you had a recent sore throat c) have you injured your chest in the last few weeks d) do you have a family hx of congenital heart disease

b) have you had a recent sore throat (Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and it would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever)

Which action by a new RN who is orienting to the telemetry unit indicates a good understanding of the treatment of heart dysrhythmias? a) prepares defibrillator settings at 360 joules for a pt whose monitor shows asystole b) injects IV adenosine over 2 seconds to a pt with supraventricular tachycardia c) turns the synchronizer to the "on" position before defibrillating a pt with ventricular fibrillation d) gives the prescribed dose of diltiazem to a pt with new-onset type II second degree AV block

b) injects IV adenosine over 2 seconds to a pt with supraventricular tachycardia (Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more teaching about treatment of heart dysrhythmias. The RN should hold the diltiazem until discussing it with the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating)

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a) explain the association between dysrhythmias and syncope b) instruct the pt to call for assistance before getting out of bed c) teach the pt about the need to avoid caffeine and other stimulants d) tell the pt about the benefits of implantable cardioverter-defibrillators

b) instruct the pt to call for assistance before getting out of bed (A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient is up. The other actions may be needed if dysrhythmias are found to be the cause of the patient's syncope but are not appropriate for syncope of unknown origin)

the nurse is assessing a pt with myocarditis before giving the scheduled dose of digoxin. Which finding is most important for the nurse to communicate to the HCP? a) leukocytosis b) irregular pulse c) generalized myalgia d) complaint of fatigue

b) irregular pulse (Myocarditis predisposes the heart to digoxin-associated dysrhythmias and toxicity. The other findings are common symptoms of myocarditis and there is no urgent need to report these)

which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? a) record hourly chest tube drainage b) monitor fluid intake and urine output c) assess the abdominal incision for redness d) teach the pt to plan for a long recovery period

b) monitor fluid intake and urine output (Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound)

which admission order written by the HCP for a pt admitted with IE and a fever would be a priority for the nurse to implement? a) administer ceftriaxone 1 g IV b) order blood cultures drawn from two sites c) give acetaminophen PRN for fever d) arrange for a transesophageal echocardiogram

b) order blood cultures drawn from two sites (Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before starting antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and acetaminophen administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority)

A pts heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The pt is unconscious, apneic, and pulseless. Which action should the nurse take first? a) give epinephrine IV b) perform immediate defibrillation c) prepare for endotracheal intubation d) ventilate with a bag-valve mask device

b) perform immediate defibrillation (The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, begin chest compressions. The other actions may also be appropriate but not first)

after receiving change of shift report on a HF unit, which pt should the nurse assess first? a) pt who is taking carvedilol and has a HR of 58 b) pt who is taking digoxin and has a K level of 3.1 c) pt who is taking captopril and has a frequent nonproductive cough d) pt who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache

b) pt who is taking digoxin and has a K level of 3.1 (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)

A pt whose heart monitor shows sinus tachycardia, rate of 132, is apneic, and has no palpable pulses. What action should the nurse take first? a) perform synchronized cardioversion b) start cardiopulmonary resuscitation (CPR) c) give atropine per agency dysrhythmia protocol d) provide supplemental O2 via non-rebreather mask

b) start cardiopulmonary resuscitation (CPR) (The patient's clinical manifestations indicate pulseless electrical activity, and the nurse should immediately start CPR. The other actions would not be of benefit to this patient)

which assessment finding in a pt who is admitted with IE is most important to communicate to the HCP? a) generalized muscle aching b) sudden onset flank pain c) Janeway's lesions on the palms d) temp 100.7 F

b) sudden onset flank pain (Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE but do not require any new interventions)

when developing a community health program to decrease the incidence of rheumatic fever, which action should the community health nurse include? a) vaccinate high-risk groups in the community with streptococcal vaccine b) teach community members to seek treatment for streptococcal pharyngitis c) teach about the importance of monitoring temperature when sore throats occur d) teach about prophylactic antibiotics to those with a family hx of rheumatic fever

b) teach community members to seek treatment for streptococcal pharyngitis (The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring temperature will not decrease the incidence of rheumatic fever)

the nurse is assessing a pt who has been admitted to the ICU with a hypertensive emergency. Which finding is most important to report to the HCP? a) urine output over 8 hours is 250 mL less than the fluid intake b) the pt cannot move the left arm and leg when asked to do so c) tremors are noted in the fingers when the patient extends the arm d) the pt complains of a headache with pain at level 7 of 10

b) the pt cannot move the left arm and leg when asked to do so (The patient's inability to move the left arm and leg indicates that a stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes)

a pt has a 6-cm TAA that was discovered during routine CXR. When obtaining an admission hx from the pt, it will be most important for the nurse to ask about: a) low back pain b) trouble swallowing c) abdominal tenderness d) changes in bowel habits

b) trouble swallowing (Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms will be important to assess for in patients with abdominal aortic aneurysms)

the nurse identifies the nursing diagnosis of decreased CO r/t valvular insufficiency for the pt with IE based on which assessment finding(s)? a) fever, chills, and diaphoresis b) urine output less than 30 mL/hr c) petechiae on the inside of the mouth and conjunctiva d) increase in HR of 15 bpm with walking

b) urine output less than 30 mL/hr (Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/min is normal with exercise)

the nurse notes that a pts heart monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a) ventricular couplets b) ventricular bigeminy c) ventricular R-on T phenomenon d) multifocal premature ventricular contractions

b) ventricular bigeminy (ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions are multifocal or that the R- on-T phenomenon is occurring)

the nurse is caring for a pt with a descending aortic dissection. Which assessment finding is most important to report to the HCP? a) weak pedal pulses b) absent bowel sounds c) BP of 138/88 d) 25 mL of urine output over the past hour

c) BP of 138/88 (The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that β-blockers or other antihypertensive drugs can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action)

the home health nurse is visiting a 30 yo pt recovering from rheumatic fever without carditis. The nurse establishes the nursing diagnosis of ineffective health maintenance r/t lack of knowledge regarding long term management of rheumatic fever when the pt makes which statement? a) I will need prophylactic antibiotic therapy for 5 years b) I can take aspirin or ibuprofen to relieve my joint pain c) I will be immune to future episodes of rheumatic fever after this infection d) I should call the HCP if I am fatigued or have difficulty breathing

c) I will be immune to future episodes of rheumatic fever after this infection (Patients with a history of rheumatic fever are more susceptible to a second episode. Patients with rheumatic fever without carditis require prophylaxis until age 20 years and for a minimum of 5 years. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance)

which assessment finding obtained by the nurse when assessing a pt with acute pericarditis should be reported immediately to the HCP? a) pulsus paradoxus 8 mmHg b) BP of 168/94 c) JVD to jaw level d) level 6 chest pain with a deep breath

c) JVD to jaw level (The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis)

a 19 yo student comes to the student health center at the end of the semester complaining that, "my heart is skipping beats." An ECG shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? a) insert an IV catheter for emergency use b) start supplemental O2 at 2 to 3 L/min via NC c) ask the pt about current stress level and caffeine use d) have the pt taken to the nearest ER

c) ask the pt about current stress level and caffeine use (In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. The patient is hemodynamically stable, so there is no indication that the patient needs supplemental O2, an IV, or to be seen in the ED)

a pt with a hx of chronic HF is admitted to the ER with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? a) auscultate the abdomen b) check the cap refill c) auscultate the breath sounds d) ask about the pts allergies

c) auscultate the breath sounds (This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is 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 also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority)

while caring for a 23 yo pt with mitral valve prolapse w/o valvular regurgitation, the nurse determines that discharge teaching has been effective when the pt states that it will be necessary to: a) take antibiotics before any dental appointments b) limit physical activity to avoid stressing the heart c) avoid OTC drugs that contain stimulants d) take an aspirin a day to prevent clots from forming on the valve

c) avoid OTC drugs that contain stimulants (Use of stimulant drugs should be avoided by patients with MVP because they may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient)

A pts heart monitor shows sinus rhythm, rate 64. The PR interval is 0.18 seconds at 0100, 0.22 seconds at 1430, and 0.28 seconds at 1600. Which action should the nurse take next? a) place the transcutaneous pacemaker pads on the pt b) give atropine sulfate 1 mg IV per agency dysrhythmia protocol c) call the HCP before giving scheduled metoprolol d) document the patient's rhythm and assess the pts response to the rhythm

c) call the HCP before giving scheduled metoprolol (The patient has progressive first-degree atrioventricular (AV) block, and the β-blocker should be held until discussing the drug with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic)

a pt who is on the telemetry unit develops atrial flutter, rate of 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a) obtain a 12 lead ECG b) notify the HCP of the change in rhythm c) give supplemental O2 at 2-3 L/min via NC d) assess the pts vital signs including O2 saturation

c) give supplemental O2 at 2-3 L/min via NC (Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by starting with O2 administration. The other actions are also important and should be implemented rapidly)

a 21 yo woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the pt? a) biologic valves will require immunosuppressive drugs after surgery b) mechanical mitral valves need to be replaced sooner than biologic valves c) lifelong anticoagulant therapy is needed after mechanical valve replacement d) ongoing cardiac care by a HCP is not necessary after valvuloplasty

c) lifelong anticoagulant therapy is needed after mechanical valve replacement (Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system and immunosuppressive therapy is not needed)

when caring for a pt on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the HCP? a) presence of flatus b) hypoactive bowel sounds c) maroon-colored liquid stool d) abdominal pain with palpation

c) maroon-colored liquid stool (Loose, bloody (maroon colored) stools at this time may indicate intestinal ischemia or infarction and should be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery)

a pt who is receiving dobutamine for the treatment of ADHF has the following nursing interventions included in the plan of care. Which action will be most appropriate for the RN to delegate to an experienced LPN/LVN? a) teach the pt the reasons for remaining on bed rest b) change the peripheral IV site according to agency policy c) monitor the pts BP and HR every hour d) titrate the rate to keep SBP>90

c) monitor the pts BP and HR every hour (An experienced LPN/LVN would be able to monitor BP and heart rate and would know to report significant changes to the RN. Teaching patients, making adjustments to the drip rate for vasoactive drugs, and inserting a new peripheral IV catheter require RN level education and scope of practice)

during discharge teaching with an older pt who had a mitral valve replacement with a mechanical valve, the nurse must instruct the pt on the: a) use of daily aspirin for anticoagulation b) correct method for taking the radial pulse c) need for frequent laboratory blood testing d) need to avoid any physical activity for 1 month

c) need for frequent laboratory blood testing (Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. This will require frequent international normalized ratio testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated)

A pt who is complaining of a "racing" heart and feeling "anxious" comes to the ER. The nurse places the pt on a heart monitor and obtains the following ECG tracing. Which action should the nurse take next? a) prepare to perform electrical cardioversion b) have the pt perform the Valsalva maneuver c) obtain the pts VS including O2sat d) prepare to give a Beta Blocker medication to slow the heart rate

c) obtain the pts VS including O2sat (The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia. Further assessment is needed before determining the treatment. Vagal stimulation or β-blockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias but would not be used for sinus tachycardia)

A pt who was admitted with a MI experiences a 45 sec episode of ventricular tachycardia, then converts to sinus rhythm with a HR of 98 bpm. Which action should the nurse take next? a) immediately notify the HCP b) document the rhythm and continue to monitor the patient c) prepare to give IV amiodarone per agency dysrhythmia protocol d) perform synchronized cardioversion per agency dysrhythmia protocol

c) prepare to give IV amiodarone per agency dysrhythmia protocol (The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Cardioversion is not indicated given that the patient has returned to a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.)

the nurse will plan discharge teaching about prophylactic antibiotics before dental procedures for which patient? a) pt admitted with a large acute MI b) pt being discharged after an exacerbation of HF c) pt who had a mitral valve replacement with a mechanical valve d) pt being treated for rheumatic fever after a streptococcal infection

c) pt who had a mitral valve replacement with a mechanical valve (Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE)

a pt has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril for management of HF. Which assessment finding by the home health nurse is a priority to communicate to the HCP? 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 K level 3 after 1 wk of therapy d) weight increase from 120 lbs to 122 lbs over 3 days

c) serum K level 3 after 1 wk of therapy (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)

Which intervention by a new nurse who is caring for a pt who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more teaching about the care of pts with ICDs? a) the nurse administers amiodarone to the patient b) the nurse helps the pt fill out the application for obtaining a Medic Alert device c) the nurse encourages the pt to do active range of motion exercises for all extremities d) the nurse teaches the pt that sexual activity can be resumed when the incision is healed

c) the nurse encourages the pt to do active range of motion exercises for all extremities (The patient should avoid moving the arm on the ICD insertion site until healing has occurred to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient)

Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? a) the procedure prevents or minimizes the risk for sudden cardiac death b) the procedure uses cold therapy to stop the formation of the flutter waves c) the procedure uses electrical energy to destroy areas of the conduction system d) the procedure stimulates the growth of new conduction pathways between the atria

c) the procedure uses electrical energy to destroy areas of the conduction system (Radiofrequency catheter ablation therapy uses electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements regarding the procedure are incorrect.)

the nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be the best to use? a) count the number of large squares in the R-R interval and divide by 300 b) print a 1-minute ECG strip and count the number of QRS complexes c) use the 3-sec markers to count the number of QRS complexes in 6 seconds and multiply by 10 d) calculate the number of small squares between one QRS complex and the next and divide into 1500

c) use the 3-sec markers to count the number of QRS complexes in 6 seconds and multiply by 10 (this is the quickest way to determine the ventricular rate for a pt with a regular rhythm. All of the other methods are accurate, but take longer)

to determine whether there is a delay in impulse conduction through the ventricles, the nurse will measure the duration of the patient's: a) P wave b) Q wave c) PR interval d) QRS complex

d) QRS complex (the QRS complex represents ventricular depolarization. The P wave represents the depolarization of the atria. The PR interval represents depolarization of the atria, AV node, bundle of His, bundle branches, and the Purkinje fibers. The Q wave is the first negative deflection following the P wave and should be narrow and short)

When analyzing the rhythm of the pts ECG, the nurse will need to investigate further upon finding a(n): a) isoelectric ST segment b) PR interval of 0.18 seconds c) QT interval of 0.38 second d) QRS interval of 0.14 second

d) QRS interval of 0.14 second (Because the normal QRS interval is less than 0.12 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The PR interval and QT interval are within normal range and ST segment should be isoelectric (flat))

The nurse has received change of shift report about the following pts on the progressive care unit. Which should the nurse see first? a) a pt with A fib, rate 88 and irregular, who has a dose of warfarin due b) a pt with second-degree AV block, type 1, rate 60, who is dizzy when ambulating c) a pt who Is in a sinus rhythm, rate 90 and regular, recovering from an elective cardioversion 2 hours ago d) a pt whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone due

d) a pt whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone due (The frequent firing of the ICD indicates that the patient's ventricles are very irritable and the priority is to assess the patient and give the amiodarone. The other patients can be seen after the amiodarone is given)

A pt develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure of 80/42, and is complaining of feeling faint. Which action should the nurse take next? a) recheck the heart rhythm and BP in 5 minutes b) have the pt perform the valsalva maneuver c) give the scheduled dose of diltiazem d) apply the transcutaneous pacemaker (TCP) pads

d) apply the transcutaneous pacemaker (TCP) pads (The patient is experiencing symptomatic bradycardia and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate and the diltiazem should be held. The Valsalva maneuver will further decrease the rate)

a pt 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 25 mg b) furosemide (Lasix) 60 mg c) digoxin (Lanoxin) 0.125 mg d) carvedilol (Coreg) 3.125 mg

d) carvedilol (Coreg) 3.125 mg (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)

the nurse obtains a health hx from an older pt with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most focused on identifying a risk factor for IE? a) do you have a hx of a heart attack? b) is there a family hx of endocarditis? c) have you had any recent immunizations? d) have you had dental work done recently?

d) have you had dental work done recently? (Dental procedures place the patient with a prosthetic mitral valve at risk for IE. Myocardial infarction, immunizations, and a family history of endocarditis are not risk factors for IE)

which nursing intervention for a pt who had an open repair of an AAA 2 days previously is appropriate for the nurse to delegate to UAP? a) monitor the quality and presence of the pedal pulses b) teach the pt the signs of possible wound infection c) check the lower extremities for strength and movement d) help the pt to use a pillow to splint while coughing

d) help the pt to use a pillow to splint while coughing (Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RNs)

several hours after a pt had an open surgical repair of an AAA, the UAP reports to the nurse that urinary output for the past 2 hrs has been 45 mL. The nurse notifies the HCP and anticipates an order for a(n): a) hemoglobin count b) additional antibiotic c) serum creatinine level d) increased IV infusion rate

d) increased IV infusion rate (The decreased urine output suggests decreased renal perfusion and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient's decreased urinary output)

the nurse has identified a nursing diagnosis of acute pain r/t inflammatory process for a pt with acute pericarditis. An appropriate intervention by the nurse for this problem is to: a) teach the pt to take deep, slow breaths to control the pain b) force fluids to 3000 mL/day to decrease fever and inflammation c) provide a fresh ice bag every hour for the pt to place on the chest d) place the pt in Fowler's position, leaning forward on the overbed table

d) place the pt in Fowler's position, leaning forward on the overbed table (Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep breaths will tend to increase pericardial pain. Ice does not decrease this type of inflammation and pain)

the nurse is caring for a pt 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 2lb in 24 hours b) hourly urine output greater than 60 mL c) reduction in patient complaints of chest pain d) reduced dyspnea with the head of bed at 30 degrees

d) reduced dyspnea with the head of bed at 30 degrees (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)

while admitting an 82 yo pt with ADHF to the hospital, the nurse learns that the pt lives alone and sometimes confuses the "water pill" with the "heart pill". When planning for the pts discharge the nurse will facilitate a: a) plan for around-the-clock care b) consultation with a psychologist c) transfer to a long-term care facility d) referral to a home health care agency

d) referral to a home health care agency (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)

Which lab result for a pt with multifocal premature ventricular contractions (PVCs) is the most important for the nurse to communicate to the HCP? a) Blood glucose of 243 mg/dL b) serum chloride of 92 mEq/L c) serum Na of 134 mEq/L d) serum K of 2.9 mEq/L

d) serum K of 2.9 mEq/L (Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values are also abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction)

the RN is caring for a pt with a hypertensive crisis who is receiving sodium nitroprusside. Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse? a) evaluate effectiveness of nitroprusside therapy on BP b) assess the pts environment for adverse stimuli that might increase BP c) titrate nitroprusside to decrease MAP to 115 d) set up the automatic noninvasive BP machine to take readings every 15 minutes

d) set up the automatic noninvasive BP machine to take readings every 15 minutes (LPN/LVN education and scope of practice include the correct use of common equipment such as automatic noninvasive blood pressure machines. The other actions require advanced nursing judgment and education, and should be done by RNs)

when discussing risk factor modification for a pt who has a 5 cm AAA, the nurse will focus teaching on which pt risk factor? a) male gender b) Turner syndrome c) abdominal trauma hx d) uncontrolled HTN

d) uncontrolled HTN (All of the factors contribute to the patient's risk, but only hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm)

the nurse obtains a rhythm strip on a pt who has had a MI and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 seconds. The nurse interprets the pts cardiac rhythm as: a) atrial flutter b) sinus tachy c) ventricular fibrillation d) ventricular tachy

d) ventricular tachy (the absence of P waves, wide QRS, rate greater than 150 bpm, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration)

which action could the nurse delegate to UAP trained as ECG techs working on the cardiac unit? a) select the best lead for monitoring a pt with an admission diagnosis of Dressler syndrome b) obtain a list of herbal medications used at home while admitting a new pt with pericarditis c) teach about the need to monitor the weight daily for a pt who has hypertrophic cardiomyopathy d) watch the heart monitor for changes in rhythm while a pt who had a valve replacement ambulates

d) watch the heart monitor for changes in rhythm while a pt who had a valve replacement ambulates (Under the supervision of registered nurses (RNs), UAPs check the patient's cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN)