CARDIAC

The nurse is planning care for a patient with acute myocardial infarction. What goals should the nurse use to guide this patient's care? (Select all that apply)1. Relieve chest pain2. Prevent complications3. Reduce blood viscosity4. Decrease cardiac workload5. Reduce myocardial damage

1,2,4,5 Immediate treatment goals for the patient with an acute myocardial infarction are to reduce chest pain, myocardial damage, decrease cardiac workload, and prevent complication. Blood viscosity is not implicated in the development of an acute MI, but plays a role in peripheral vascular resistance.

The nurse should assess the client with left-sided heart failure for which findings? Select all that apply.1. dyspnea2. jugular vein distention (JVD)3. crackles4. right upper quadrant pain5. oliguria6. decreased oxygen saturation levels

1,3,5,6. Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JVD and right upper quadrant pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in right-sided heart failure

The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?1. Assess respiratory status.2. Draw blood for laboratory studies.3. Insert a Foley catheter.4. Weigh the client.

1. The ankle edema suggests fluid volume overload. The nurse should assess respiratory rate, lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client.

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and CRT less than three (3) seconds.

1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1. Bradycardia 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 3401 4. Falling central venous pressure

2 Rationale: Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1. Stridor 2. Crackles 3. Scattered rhonchi 4. Diminished breath sounds

2 Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.

A nurse working the day shift on a cardiac unit receives the following shift report:1. Client 1: Admitted yesterday morning with hypokalemia. Awaiting repeat electrolyte lab results drawn at 06:00. 7692. Client 2: Experienced chest pain at 06:30. Pain resolved after 2 sublingual nitroglycerin tablets.3. Client 3: Scheduled for oral antihypertensive medications at 0900. Incontinent of urine during the night. 4. Client 4: Scheduled for coronary artery bypass surgery at 0800. The client's family is in the client's room.

2,4,3,1. Even though the chest pain experienced by Client 2 is resolved, it was recent and requires reassessment. Client 4 is scheduled to leave for major surgery very soon. The nurse should check this client and the client's chart and make certain that everything is ready so as to not delay the surgery. Client 3 has scheduled medications for blood pressure control. While not experiencing any acute problems, this medication should be admin

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.

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.

A client arrives in the emergency department complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. The nurse determines that this result indicates which finding? 1. A normal level 2. A low value that indicates possible gastritis 3. A level that indicates a myocardial infarction 4. A level that indicates the presence of possible angina

3 Rationale: Troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is lower than 0.6 ng/mL.

The nurse's discharge teaching plan for the client with heart failure should emphasize the importance of:1. maintaining a high-fiber diet.2. walking 2 miles (3.2 km) every day.3. obtaining daily weights at the same time each day.4. remaining sedentary for most of the day.

3. Heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the healthcare provider (HCP) if there has been a weight gain of 2 lb (0.91 kg) or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening. Following a high-fiber diet is beneficial, but it is not relevant to the teaching needs of the client with heart failure.

Which position is best for a client with heart failure who has orthopnea?1. semisitting (low Fowler's position) with legs elevated on pillows2. lying on the right side (Sims' position) with a pillow between the legs3. sitting upright (high Fowler's position) with legs resting on the mattress4. lying on the back with the head lowered (Trendelenburg's position) and legs elevated

3. Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate Trendelenburg's position.

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.

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

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse?1. The client diagnosed with congestive heart failure who is being discharged in the morning.2. The client who is having frequent incontinent liquid bowel movements and vomiting.3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62.4. The client who is complaining of chest pain on inspiration and a nonproductive cough.

3. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client.

Which are indications that a client with a history of left-sided heart failure is developing pulmonary edema? Select all that apply.1. distended jugular veins2. dependent edema3. anorexia4. coarse crackles5. tachycardia

4,5. Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia occurs due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated, depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.

Which is an expected outcome for a client on the 2nd day of hospitalization after a myocardial infarction (MI)? The client:1. continues to have severe chest pain.2. can identify risk factors for MI.3. participates in a cardiac rehabilitation walking program.4. can perform personal self-care activities without pain

4. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program

A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads, and troponin levels are elevated. What should the nurse do first?1. Monitor daily weights and urine output.2. Limit visitation by family and friends.3. Provide client education on medications and diet.4. Reduce pain and myocardial oxygen demand

4. Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment.

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?1. Sponge the client's forehead2. Obtain a pulse oximetry reading3. Take the client's vital signs4. Assist the client into a sitting position

4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then the nurse would take vital signs and check the pulse oximeter and then sponge the client's forehead.

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?1. Sponge the client's forehead.2. Obtain a pulse oximetry reading.3. Take the client's vital signs.4. Assist the client to a sitting position.

4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead

The nurse is caring for a postoperative client who has limited mobility. Which assessment finding should the nurse report as a possible sign of a deep venous thrombosis​ (DVT)? (Select all that​ apply.) A. Aching of the left calf B. Pale skin color of the left lower leg C. Area of redness along a left lower leg vein D. Swelling of the left lower leg E. Muscle twitching of the left thigh

A. Aching of the left calf B. Pale skin color of the left lower leg C. Area of redness along a left lower leg vein D. Swelling of the left lower leg

A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?1.Auscultate the client's breath sounds2.Encourage the client to increase fluid intake3.Report the findings to the health care provider (HCP)4.Start an intravenous line for diuretic administration

ANS 1 The nurse should assess the lung sounds for crackles and report to the HCP, who can prescribe loop diuretics.

A 70-year-old female client with type 2 diabetes mellitus comes to the emergency department with diaphoresis, nausea, generalized weakness, and epigastric burning pain. Which intervention should the nurse implement first?1.Administer 2 mg morphine IV2.Assess fingerstick blood glucose3.Draw blood for basic metabolic panel4.Obtain a 12-lead electrocardiogram

ANS 4The nurse should obtain a 12-lead electrocardiogram (ECG) on any client with atypical MI symptoms to assess for evidence of ischemia, injury, or infarction (Option 4). ST-segment elevation MI is life-threatening and requires rapid coronary intervention.(Option 1) Morphine is administered to relieve pain and anxiety. A 12-lead ECG must be obtained to verify that the symptoms are cardiac in nature before giving medications.(Option 2) In clients with diabetes, diaphoresis may indicate hypoglycemia, but other symptoms, such as epigastric pain, in this client make MI more likely.(Option 3) Nausea and generalized weakness may result from some electrolyte imbalances, and the nurse should send blood for routine studies (eg, basic metabolic panel, complete blood count). However, a 12-lead ECG will give more immediate assessment information, allowing for quicker intervention if MI is present.

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first?1. The client diagnosed with myocardial infarction who has an audible S3 heart sound.2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema.3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%.4. The client with chronic renal failure who has an elevated creatinine level.

ANS : 1 1. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation.2. The nurse would expect a client with CHF to have sacral edema of 4+; the client with an S3 would be in a more life-threatening situation.3. A pulse oximeter reading of greater than 93% is considered normal.4. An elevated creatinine level is expected in a client diagnosed with chronic renal failure.

When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first?1.Assess for jugular venous distension2.Attach the cardiac monitor to the client3.Auscultate heart and breath sounds4.Obtain the client's vital signs

ANS : 2 Dysrhythmias are the most frequent complication following myocardial infarction (MI). Ventricular fibrillation is the most common of these dysrhythmias and is regularly the cause of sudden cardiac death in clients with MI. The nurse should attach the cardiac monitor to the client before performing any other interventions.

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

ANS : 2,3 1. Morphine should be administered intravenously, not intramuscularly.2. Aspirin is an antiplatelet medication and should be administered orally.3. Oxygen will help decrease myocardial ischemia, thereby decreasing pain.4. The supine position will increase respiratory effort, which will increase myocardial oxygen consumption; the client should be in the semi-Fowler's position.5. Nitroglycerin, a coronary vasodilator, is administered sublingually, not subcutaneously.

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? Select all that apply.1.Crackles in lung bases2.Increased abdominal girth3.Jugular venous distension4.Lower extremity edema5.Orthopnea

ANS : 2,3,4Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities (Option 4).Jugular venous distension (Option 3).Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and ascites. Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation (Option 2).Hepatomegaly due to hepatic venous congestion.(Options 1 and 5) Orthopnea (dyspnea with recumbency), paroxysmal nocturnal dyspnea (PND), and crackles in lung bases are clinical manifestations of left-sided heart failure. Blood is not effectively pumped into systemic circulation, resulting in the backup of blood into the pulmonary vessels that causes congestion of the pulmonary vessels and, potentially, pulmonary edema. Pulmonary hypertension and right-sided heart failure typically present with dyspnea on exertion rather than orthopnea or PND.

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure?1.Arterial blood gases (ABGs)2.B-type natriuretic peptide (BNP)3.Cardiac enzymes (CK-MB)4.Chest x-ray

ANS : 2Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea.

A 62-year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority?1.Ask the client how long the leg has been tender and warm2.Assess the electrocardiogram (ECG) for any ectopic beats3.Check vital signs including pulse oximetry4.Complete neurovascular assessment on lower extremities

ANS : 4 The priority action by the nurse should include a thorough neurovascular assessment of the extremities, including presence and quality of dorsalis pedis (DP) and posterior tibial (PT) pulses, temperature of the extremities, capillary refill, and circumference measurements of both calves and thighs. Both extremities should be assessed for comparison.(Options 1, 2, and 3) These are all assessments that the nurse should collect to report to the HCP but are not as high of a priority or as relevant to the specific situation that the client is currently experiencing.

The nurse identifies the collaborative problem of potential complication: pulmonary edema for a patient in ADHF. When assessing the patient, the nurse will be most concerned abouta. an apical pulse rate of 106 beats/min.b. an oxygen saturation of 88% on room air.c. weight gain of 1 kg (2.2 lb) over 24 hours.d. decreased hourly patient urinary output.

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

When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such asa. administering sedatives to promote rest and decrease myocardial oxygen demand.b. positioning the patient in a high-Fowler's position with the feet horizontal in the bed.c. administering oxygen per mask or nasal cannula.d. encouraging leg exercises to improve venous return.

B Rationale: Positioning the patient in a high-Fowler's position with the legs dependent will reduce preload by decreasing venous return to the right atrium. The other interventions may also be appropriate for patients with heart failure but will not help in decreasing preload.

The nurse is teaching a client with atrial fibrillation about deep venous thrombosis prevention. Which should the nurse instruct the client to avoid​? ​(Select all that​ apply.) Extreme exercise Crossing the legs Prolonged sitting​ Tight-fitting clothing Prolonged standing

Crossing the legs Prolonged sitting​ Tight-fitting clothing Prolonged standing

Treatment options for venous stasis ulcers in the lower extremities include: A. cleansing with hydrogen peroxide B. applying Burrow solution C. prescribing a systemic corticosteroid D. applying a moisture retaining dressing

D

A 73-year-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient and his caregiver? a Low-fat diet b High-protein diet c Calorie-restricted diet d High-carbohydrate diet

Correct Answer: B A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. Restricting fat or calories is not helpful for wound healing or in patients of normal weight. For overweight individuals with no active venous ulcer, a weight-loss diet should be considered.

The nurse is providing a cardiac class for a women's group. The nurse emphasizes that which characteristics place women at high risk for myocardial infarction (MI)? Select all that apply. Premenopausal Increasing age Family history Abdominal obesity Breast cancer

Increasing age, especially after 70 yo Family history is a risk factor in both men and women Abdominal obesity: A large waist size/abdominal obesity is a risk factor for both metabolic syndrome and MI.

Which topic will the nurse include in patient teaching for a patient with a venous stasis ulcer on the right lower leg?A. Adequate carbohydrate intakeB. Prophylactic antibiotic therapyC. Application of compression to the legD. Methods of keeping the wound area dry

c (Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used forvenous ulcers. Moist environment dressings are used to hasten wound healing)

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 3400 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler's side-lying position

1, 2, 3, 4 Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is toa. auscultate the lung sounds.b. assess the orientation.c. check the capillary refill.d. palpate the abdomen.

A Rationale: When caring for a patient with severe dyspnea, the nurse should use the ABCs to guide initial care. 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 should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority.

The nurse is admitting a client with heart failure-related fluid overload. Which action should the nurse complete first?1.Administer oxygen2.Assess the client's breath sounds3Initiate cardiac monitoring4.Insert a peripheral IV catheter

ANS : 2Therefore, the nurse should first assess the client's breath sounds (Option 2). Rales or "crackles" may be auscultated in the lungs as a result of pulmonary congestion.(Option 1) The client's current respiratory status (ie, breath sounds, oxygen saturation) must be evaluated prior to giving oxygen. Oxygen saturation should be assessed upon admission and every 4-6 hours based on hospital protocol; oxygen is subsequently administered based on client needs.(Option 3) It is appropriate for this client to have continuous cardiac monitoring that can alert staff to life-threatening rhythms (eg, ventricular tachycardia) if they occur. However, the client's respiratory status should be assessed first.(Option 4) This client will require IV administration of diuretics, such as furosemide, to reduce excess fluid volume and preload. A peripheral IV catheter should be placed, but assessment of the client's current status takes priority.

In planning care and patient teaching for the patient with venousleg ulcers, the nurse recognizes that the most important interventionin healing and control of this condition is a. sclerotherapy. b. using moist environment dressings. c. taking horse chestnut seed extract daily. d. applying elastic compression stockings.

Correct answer: d Rationale: Compression is essential for treating chronic venous insufficiency (CVI), healing venous ulcers, and preventing ulcer recurrence. Use of custom-fitted elastic compression stockings is one option for compression therapy.

The nurse teaches the client that the major difference between angina and pain associated with myocardial infarction (MI) is that:a) Angina can be fatal.b) Myocardial infarction pain always radiates to the left arm or jaw.c) Angina is relieved with nitroglycerin and rest.d) Both types of pain are treated the same.

c) Angina is relieved with nitroglycerin and rest.Rationale: Angina pain is uncomfortable, but it rarely is fatal. It usually is relieved immediately by nitroglycerin. Pain from a myocardial infarction does not always radiate to the jaw or arm. Angina pain is treated differently than MI pain.

A patient is admitted with chest pain to the ER. The patient has been in the ER for 5 hours and is being admitted to your unit for overnight observation. From the options below, what is the most IMPORTANT information to know about this patient at this time? A. Troponin result and when the next troponin level is due to be collected B. Diet status C. Last consumption of caffeine D. CK result and when the next CK level is due to be collected

The answer is A. The key words in this question are "chest pain" and "been in the ER for 5 hours". The patient should have already had one troponin level drawn since it starts to elevate 2-4 hours after injury and has been in the ER for 5 hours. Therefore, it is essential you know what the level is and when the next level is due. If the patient's chest pain is caused by a myocardial event the troponin levels will trend upward. Troponin levels are usually ordered every 6 hours x 3. CK results are not as specific as a troponin levels. This question wanted to know the MOST important, and the troponin level for this patient/when it is drawn next is MOST important. Diet status and last consumption of caffeine are things the nurse needs to know but not the MOST important.

You're developing a plan of care for a patient who is at risk for the development of a deep vein thrombosis after surgery. What nursing intervention below would the nurse NOT include in the patient's plan of care to prevent DVT formation? A. The patient will eat all meals out of the bed daily by sitting in the bedside chair. B. The nurse will apply sequential compression devices (SCDs) per physician's order to the patient's lower extremities every night at bedtime. C. The nurse will administer per physician's order Enoxaparin in the subcutaneous tissue of the abdomen. D. The patient will ambulate daily.

The answer is B. Yes, the nurse would apply SCDs per MD order to help prevent DVTs, BUT they are to be applied and worn by the patient anytime they are in bed or sitting. The only time a patient should not wear the SCDs is when they're ambulating. Therefore, the nurse would NOT just apply them at bedtime but during the day too.

A doctor has ordered cardiac enzymes on a patient being admitted with chest pain. You know that _____________ levels elevate 2-4 hours after injury to the heart and is the most regarded marker by providers. A. Myoglobin B. CK-MB C. CK D. Troponin

The answer is D.

A patient is complaining of chest pain. On the bedside cardiac monitor you observe pronounce T-wave inversion. You obtain the patient's vital signs and find the following: Blood pressure 190/98, HR 110, oxygen saturation 96% on room air, and respiratory rate 20. Select-all-that-apply in regards to the MOST IMPORTANT nursing interventions you will provide based on the patient's current status: A. Obtain a 12-lead EKG B. Place the patient in supine position C. Assess urinary output D. Administer Nitroglycerin sublingual as ordered per protocol E. Collect cardiac enzymes as ordered per protocol F. Encourage patient to cough and deep breath G. Administer Morphine IV as ordered per protocol H. Place patient on oxygen via nasal cannula I. No interventions are needed at this time

The answers are A, D, E, G, and H.

Your patient has a deep vein thrombosis in the left lower extremity. The patient is prescribed continuous IV Heparin. Select all the nursing interventions that are appropriate for this patient: A. Apply cool compresses to affected extremity B. Measure leg circumference C. Massage affected extremity D. Elevate affected extremity above heart level E. Encourage frequent ambulation F. Monitor the patient's INR level G. Monitor the patient's aPTT level H. Apply sequential compression device (SCD) to the affected extremity

The answers are B, D, G. Nursing interventions for this patient include: measuring leg circumference, elevating affected extremity above heart level, and monitoring aPTT level (for Heparin therapy). Why are the other options wrong? Option A: WARM compresses should be used, NOT cool (this will help with pain and circulation), Option C: this could dislodge the clot (NEVER massage or rub the site), Option E: the patient needs bed rest...ambulation could dislodge the clot, Option F: INR level is used to monitor Warfarin NOT Heparin, Option H: SCDs are NOT applied to an extremity with a clot because it could dislodge the clot...they are used to PREVENT blood clots.

The most important measure in the treatment of venous stasis ulcers is...A. elevation of the limbB. extrinsic compressionC. application of moist dressingsD. application of topical antibiotics

b (Although leg elevation, moist dressings, and topical antibiotics are useful in treatment of venous stasis ulcers, the most important factor appears to be extrinsic compression to minimize venous stasis, venous hypertension, and edema. Extrinsic compression methods include compression gradient stockings, elastic bandages, and Unna's boot.)