MS4 Final
12c. What are the contraindications to thrombolytic use in the treatment of ST-elevation myocardial infarction?
"1. Recent cerebrovascular accident (CVA) 2. Active bleeding, severe hypertension 3. Anticoagulant therapy 4. Brain tumor
"19. When caring for a patient with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome (select all that apply)? A. Use smallest gauge needle possible when giving injections or drawing blood. B. Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing. C. Advise patient to use soft-bristle toothbrush and avoid ingestion of irritating food. D, Apply gentle pressure for the shortest possible time period after performing venipuncture. E. Instruct patient to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present."
"A, B, C, E Using the smallest gauge needle for injections will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The use of a soft-bristle toothbrush and avoidance of irritating food will reduce injury to highly vascular mucous membranes. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding.
"16b. The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? A. ""If I notice a fast heart rate or irregular beats, this is normal for cirrhosis."" B. ""I need to take good care of my belly and ankle skin where it is swollen."" C. ""A scrotal support may be more comfortable when I have scrotal edema."" D. ""I can use pillows to support my head to help me breathe when I am in bed."""
"A. ""If I notice a fast heart rate or irregular beats, this is normal for cirrhosis."" If the patient with cirrhosis experiences a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider, as this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position will increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.
25a. You are an emergency room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results? A) Respiratory acidosis with no compensation. B) Metabolic alkalosis with a compensatory alkalosis. C) Metabolic acidosis with no compensation. D) Metabolic acidosis with a compensatory respiratory alkalosis"
"D) Metabolic acidosis with a compensatory respiratory alkalosis. A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH of bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.
25c. A nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30, and HCO3- of 22. The nurse analyzes these results as indicating which condition? 1) Metabolic Acidosis, compensated 2) Respiratory Alkalosis, compensated 3) Metabolic Alkalosis, compensated 4) Respiratory Acidosis, compensated"
2) The normal pH is 7.35-7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In this condition, the pH is a the high end of normal and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore the values identified in the question indicated a respiratory alkalosis. When the pH returns to a normal value, compensation has occurred.)
"14. The patient with cirrhosis has an increased abdominal girth from ascites. The nurse should know that this fluid gathers in the abdomen for which reasons (select all that apply)? A. There is decreased colloid oncotic pressure from the liver's inability to synthesize albumin. B. Hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention. C, Portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity. D, Osmoreceptors in the hypothalamus stimulate thirst, which causes the stimulation to take in fluids orally. E. Overactivity of the enlarged spleen results in increased removal of blood cells from the circulation, which decreases the vascular pressure."
A, B, C - The ascites related to cirrhosis are caused by decreased colloid oncotic pressure from the lack of albumin from liver's inability to synthesize it and the portal hypertension that shifts the protein from the blood vessels to the peritoneal cavity, and hyperaldosteronism which increases sodium and fluid retention. The intake of fluids orally and the removal of blood cells by the spleen do not directly contribute to ascites.
"8. A patient who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. What aspect of the patients health history creates a heightened risk of intracardiac thrombi? A) Atrial fibrillation B) Infective endocarditis C) Recurrent pneumonia D) Recent surgery"
A. Intracardiac thrombi are especially common in patients with atrial fibrillation, because the atria do not contract forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia, and recent surgery do not normally cause an increased risk for intracardiac thrombi formation.
"21a. The nurse performs acute intermittent peritoneal dialysis (PD) on a client who is experiencing uremic signs and symptoms. The peritoneal fluid is not draining as expected. What is the best response by the nurse? A. Notify the health care provider. B. Turn the client from side to side. C. Lower the head of the bed. D. Push the catheter further into the abdomen."
B. If the peritoneal fluid does not drain properly, the nurse can facilitate drainage by turning the client from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. Other measures to promote drainage include checking the patency of the catheter by inspecting for kinks, closed clamps, or an air lock.
" The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive highest priority? A. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles B. Confusion, urine output 15mL over the last 2 hours, orthopnea. C. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities. D. Weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise."
B. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation there is a loss of atrial kick, but the blood pressure and heart rate are stable
" "17. The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit? A. Hematochezia B. Left upper abdominal pain C. Ascites and peripheral edema D. Temperature over 102º F (38.9ºC)"
B. Abdominal pain (usually in the left upper quadrant) is the predominant manifestation of acute pancreatitis. Other manifestations of acute pancreatitis include nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness with muscle guarding is common. Bowel sounds may be decreased or absent. Ileus may occur and causes marked abdominal distention. Areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall may occur. Other areas of ecchymoses are the flanks (Grey Turner's spots or sign, a bluish flank discoloration) and the periumbilical area (Cullen's sign, a bluish periumbilical discoloration).
"21b. Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? A. Blood glucose level of 200 mg/dl B. White blood cell (WBC) count of 20,000/mm3 C. Potassium level of 3.5 mEq/L D. Hematocrit (HCT) of 35%"
B. An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes, therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia (evidenced by a blood glucose level of 200 mg/dl) occurs during peritoneal dialysis because of the high glucose content of the dialysate it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.
"5c. The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock? A) The patient admitted with acute renal failure B) The patient admitted following an MI C) The patient admitted with malignant hypertension D) The patient admitted following a stroke"
B. Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic, necrotic, and hypokinetic. It also can occur as a result of end-stage heart failure, cardiac tamponade, pulmonary embolism, cardiomyopathy, and dysrhythmias. While patients with acute renal failure are at risk for dysrhythmias and patients experiencing a stroke are at risk for thrombus formation, the patient admitted following an MI is at the greatest risk for development of cardiogenic shock when compared with the other listed diagnoses.
"15. The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? A. Immediately start enteral feeding to prevent malnutrition. B. Insert an NG and maintain NPO status to allow pancreas to rest. C. Initiate early prophylactic antibiotic therapy to prevent infection. D. Administer acetaminophen (Tylenol) every 4 hours for pain relief."
B. Insert an NG and maintain NPO status to allow pancreas to rest. Initial treatment with acute pancreatitis will include an NG tube if there is vomiting and being NPO to decrease pancreatic enzyme stimulation and allow the pancreas to rest and heal. Fluid will be administered to treat or prevent shock. The pain will be treated with IV morphine because of the NPO status. Enteral feedings will only be used for the patient with severe acute pancreatitis in whom oral intake is not resumed. Antibiotic therapy is only needed with acute necrotizing pancreatitis and signs of infection.
"6. Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important 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"
B. Pallor and weakness of the right hand. 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.
"7. 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"
B. Patient w/ stable angina 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 stable.
"4a. The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding? A) This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. B) Because the patient has a history of unstable angina, this is a poor indicator of myocardial injury. C) This is an accurate indicator of myocardial injury. D) This result indicates muscle injury, but does not specify the source."
C - Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even with a diagnosis of unstable angina, this is an accurate indicator of myocardial injury.
"12a. A patient presents to the emergency department with symptoms of acute myocardial infarction. After a diagnostic workup, the healthcare provider prescribes a 15-mg IV bolus of alteplase (tPA), followed by 50 mg infused over 30 minutes. In monitoring this patient, which finding by the nurse most likely indicates an adverse reaction to this drug? A) Urticaria, itching, and flushing B) Blood pressure of 90/50 mm Hg C) Decreasing level of consciousness D) Potassium level of 5.5 mEq/L"
C) Decreasing level of consciousness - 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.
"16a. The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? A. ""It is safe to take acetaminophen up to four times a day for pain."" B. ""Lactulose (Cephulac) should be taken every day to prevent constipation."" C. ""Herbs and other spices should be used to season my foods instead of salt."" D. ""I will eat foods high in potassium while taking spironolactone (Aldactone)."""
C. A low-sodium diet is indicated for the patient with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided as these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.
"3. A patient who has chest pain is admitted to the emergency department (ED), and all of the following are ordered. 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"
C. ECG 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.
13.The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? A. Serum α-fetoprotein level B. Ventilation/perfusion scan C. Hepatic structure ultrasound D. Abdominal girth measurement"
C. Hepatic structure ultrasound -- hepatic structure ultrasound, CT, and MRI are used to screen and diagnose liver cancer. Serum α-fetoprotein level may be elevated with liver cancer or other liver problems. Ventilation/perfusion scans do not diagnose liver cancer. Abdominal girth measurement would not differentiate between cirrhosis and liver cancer.
"9. IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops: a. ventricular ectopy. b. a dry, hacking cough. c. a systolic BP <90 mm Hg. d. a heart rate <50 beats/minute."
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.
"23. During treatment of a patient with a Sengstaken-Blakemore tube for bleeding esophageal varices, which nursing action will be included in the plan of care? a. Encourage the patient to cough and deep breathe. b. Insert the tube and verify its position q4hr. c. Monitor the patient for shortness of breath. d. Deflate the gastric balloon q8-12hr."
C. The most common complication of a Blakemore tube is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. The health care provider inserts the tube and verifies the position. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.
"5a. A patient is recovering from a myocardial infarction (MI) and 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 next? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias."
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.
25b. The nurse is planning care for the client who has been admitted with metabolic alkalosis. Which are appropriate nursing diagnoses for this client during the acute phase of the illness? (SATA) A) Ineffective Health Maintenance B) Risk for Hypothermia C) Deficient Fluid Volume D) Risk for Impaired Gas Exchange E) Risk for Injury"
CDE Respiratory compensation for metabolic alkalosis includes depression of the respiratory rate and reduction of the depth of respirations, leading to the retention of carbon dioxide. Patients with metabolic alkalosis often have an accompanying fluid volume deficit. With the fluid volume deficit, the client would experience hyperthermia. Ineffective health maintenance would not be a priority during the acute phase of the disease but, rather, a teaching opportunity before discharge depending on the cause of the metabolic alkalosis. The client is at risk for injury because of the associated muscle spasms and dizziness.)
12b. A nurse is caring for a patient who had an embolism stroke and has a new prescription for alteplase. What in the patient's history would be a contraindication for alteplase?
Contraindications: severe uncontrolled hypertension, intracranial or subarachnoid hemorrhage, internal bleeding, recent intracranial or intraspinal surgery, and patient with recent head trauma
"4b. 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 should the nurse monitor to best determine whether the patient has had an AMI? A. Myoglobin B. Homocysteine C. C-reactive protein D. Cardiac-specific troponin"
D Troponin - 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.
"The nurse is reviewing the latest arterial blood gas results for a client with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated? A) pH 7.32 B) PaCO2 18 mmHg C) HCO3 8 mEq/L D) PaCO2 48 mmHg"
D) A normal pH level is 7.35-7.45. A pH of less than 7.35 is acidosis. A PaCO2 level of 18 mmHg is low and is seen in respiratory alkalosis. A HCO3 level of 8 mEq/L is low and is most likely associated with metabolic acidosis. In metabolic alkalosis, there is an excess of bicarbonate. To compensate for this imbalance, the rate and depth of respirations decrease, leading to retention of carbon dioxide. The PaCO2 will be elevated.
"18. When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A. Impaired skin integrity related to edema, ascites, and pruritus B. Imbalanced nutrition: less than body requirements related to anorexia C. Excess fluid volume related to portal hypertension and hyperaldosteronism D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume"
D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume - Although all of these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.
21c. A client, aged 87, undergoes continuous ambulatory peritoneal dialysis (CAPD) for acute renal failure (ARF). Which task would be most important for the nurse to do? A. Monitor the client for hypoglycemia and hyperglycemia. B. Ensure a diet rich in proteins and potassium. C. Note a color change in the client's eyes, teeth, and nails. D. Frequently monitor the client's progress."
D. Older clients who are not candidates for kidney transplants may receive CAPD. More frequent monitoring of the client's progress is required when this technique is used. The recommendations for protein and potassium in the diet are highly variable based on the client's condition. Change in the color of client's teeth, eyes, and nails need not be monitored, nor does the client need to be monitored for hypoglycemia and hyperglycemia.
"1c. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching 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 still have pain after taking three nitroglycerin 5 minutes apart."""
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.
"2. Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for: A. decreased blood pressure and heart rate. B. fewer complaints of having cold hands and feet. C. improvement in the strength of the distal pulses. D. the ability to do daily activities without chest pain."
D. the ability to do daily activities without chest pain. 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 noncardioselective -adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.
1a. How to self-administer nitroglycerin
Take maximum three sublingual tablets at 5-minute intervals - if pain persists after 3 doses call 911
20. A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority? A. Alert the health care provider. B. Put client on NPO status C. Sit the client up in high-Fowler's position. D. Flush the catheter "
The assessment is indicative of peritonitis or infection associated with the peritoneal dialysis catheter. The health care provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Sitting the client up may aggravate the pain. Flushing the catheter does not address the likely infection. The nurse should attempt to keep the client in the most comfortable position possible until a prescription is received from the health care provider.
1b. Side effects of nitro
Vasodilation: flushing, throbbing headache, hypotension, and tachycardia - patient should sit down for safety
"22. When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? a. Auscultate for a bruit at the fistula site. b. Assess the quality of the left radial pulse. c. Compare blood pressures in the left and right arms. d. Irrigate the fistula site with saline every 8 to 12 hours"
a. auscultate for a bruit at the fistula site
"5b. 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 ever having a heart attack. c. Bilateral crackles are auscultated in the mid-lower lobes. d. The patient has occasional premature atrial contractions (PACs)."
c. Bilateral crackles are auscultated in the mid-lower lobes. 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 (ACE) 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.
"24. A patient complains of leg cramps during hemodialysis. The nurse should first a. massage the patient's legs. b. reposition the patient supine. c. give acetaminophen (Tylenol). d. infuse a bolus of normal saline."
d. infuse a bolus of saline Muscle cramps during dialysis are caused by rapid removal of sodium and water. Treatment includes infusion of normal saline. The other actions do not address the reason for the cramps.