Exam 4

List in order the pathway of the normal cardiac impulse starting at the SA node.

1. The impulse causes the atria to contract. 2. The impulse travels from the AV node through the bundle of His. 3. The impulse divides into the left and right bundle branches. 4. The impulse reaches the Purkinje fibers. 5. The ventricles contract. Rationale: The SA node begins the normal cardiac cycle. The impulse travels from the SA node in the upper right atrium to the intertribal and intermodal pathways. The atrium contracts. The impulse continues to the AV node following the bundle of His to the bundle branches. The impulse ends in the Purkinje fibers that send the impulse to the ventricles. The ventricles then contract.

The nurse reviews the medical records of several patients. Which patients are at high risk of developing hypertension? Select all that apply. A. A 65-year-old black woman B. An older adult man who smokes C. A 35-year-old man who is obese D. A female teenager with a fractured humerus E. A 50-year-old man whose parent had hypertension

A. A 65-year- old black woman B. An older adult man who smokes C. A 35-year-old man who is obese E. A 50-year-old man whose parent had hypertension Rationale: Blacks have an increased risk of developing hypertension compared with their white counterparts. In addition, the woman is 65 years old; in females, the risk of hypertension increases after 50 years of age. An elderly man is at risk of hypertension because of his age. In addition, smoking increases the risk of developing hypertension. Obesity increases the risk of hypertension. A person who has a family history of hypertension is at increased risk of developing hypertension. A female teenager with a fracture is not at risk because of her young age and female gender.

A nurse provides discharge education to a patient about the care and management of hypertension. Which information would the teaching plan include? Select all that apply. A. Explain the meaning of the BP values. B. Remind the patient to supplement the diet with foods high in sodium. C. Explain the potential dangers of uncontrolled hypertension. D. Assure the patient that short-term therapy will cure hypertension. E. Exercise after taking the medication prescribed for hypertension. F. Do not alter medication dosage without consulting the health care provider.

A. Explain the meaning of the BP values. C. Explain the potential dangers of uncontrolled hypertension. F. Do not alter medication dosage without consulting the health care provider. Rationale: The nurse should explain the meaning of the systolic BP (SBP) and diastolic BP (DBP) values. The nurse should also explain the potential dangers of uncontrolled hypertension and the dangers of altering the dosage without consulting the health care provider. The nurse should inform the patient that long-term therapy and follow-up care are essential to treat hypertension and that therapy will not cure but should control hypertension. The patient should avoid foods high in sodium; instead, supplement the diet with foods high in potassium. The patient should avoid strenuous exercise, hot baths, and excessive amounts of alcohol within three hours of taking the medication prescribed for hypertension.

A patient is diagnosed with primary hypertension. Which factors in the patient's history likely contributed to the development of the hypertension? Select all that apply. A. Tobacco use B. Thyroid disease C. Diabetes mellitus D. Increased sodium intake E. Greater-than-ideal body weight F. Underproduction of sodium-retaining hormones

A. Tobacco use C. Diabetes mellitus D. Increased sodium intake E. Greater-than-ideal body weight Rationale: Contributing factors to primary hypertension include tobacco use, diabetes mellitus, increased sodium intake, and greater-than-ideal body weight. Thyroid disease is related to secondary hypertension. Overproduction (not underproduction) of sodium-retaining hormones contribute to primary hypertension.

The nurse analyzes a patient's electrocardiogram (ECG) and determines that there are 8 R-R intervals in a span of six seconds. What should the nurse document as the patient's heart rate? Record the answer using a whole number. ________ beats/min.

Answer: 80 beats/min Rationale: The heart rate can be calculated from an ECG by counting the number of R-R intervals in six seconds and multiplying that number by 10. In this case, the patient's ECG has eight R-R intervals. Therefore 8 multiplied by 10 is 80. pp. 756-757

The nurse is teaching a student about pulmonary embolism. Which response by the student indicates to the nurse teaching was effective? A. "A clot in the iliac vein may lead to a potentially lethal pulmonary emboli." B. "A clot in the portal vein may lead to a potentially lethal pulmonary emboli." C. "A clot in the jugular vein may lead to a potentially lethal pulmonary emboli." D. "A clot in the lumbar vein may lead to a potentially lethal pulmonary emboli."

Answer: A. "A clot in the iliac vein may lead to a potentially lethal pulmonary emboli." Rationale: Pulmonary embolism is a blockage of the pulmonary artery by thrombus air or fat embolus, or tumor cells. About 90% of pulmonary emboli results from deep vein thrombosis in the deep veins of the legs, such as the iliac vein. Lethal pulmonary emboli are less likely the result of thrombus in the portal vein, jugular vein, and lumbar vein because they rarely migrate to the pulmonary circulation. pp. 532-533

Which statement describes the reason amlodipine may be used to treat a patient with multiple organ dysfunction syndrome (MODS) who exhibits acute changes in their neurologic status? A. "Amlodipine is being used to reduce cerebral vasospasm." B. "The amlodipine is being used to treat low BP." C. "Amlodipine is the drug of choice to increase oxygen delivery to the other organs." D. "The amlodipine will help to decrease the need for oxygen."

Answer: A. "Amlodipine is being used to reduce cerebral vasospasm." Rationale: Calcium channel blockers like amlodipine are used to reduce cerebral vasospasm in patients with MODS. They block uptake of calcium into the myocardium resulting in vasodilation. Amlodipine does not increase BP; it decreases BP. Amlodipine can increase oxygen delivery to cardiac and other muscles and decrease the need for oxygen, but that is not the indicated use in MODS. pp. 1584-1585

The nurse provides discharge teaching to a patient who is newly diagnosed with coronary artery disease (CAD). Which statement made by the patient indicates understanding of the needed dietary modifications? A. "I will not eat bacon or sausage products." B. "I will not eat fish more than once a week." C. "I will eat fried eggs instead of boiled eggs." D. "I will drink one glass of whole milk per day."

Answer: A. "I will not eat bacon or sausage products." Rationale: Nutritional guidelines recommended for the patient with CAD include a low-cholesterol and low-fat diet; therefore the patient has to avoid bacon and sausage products. Fish is high in omega-3 fatty acids, which reduce triglyceride levels and can slow the progression of CAD. The American Heart Association (AHA) recommends eating fish twice a week. Egg yolk is high in cholesterol, and the patient with CAD has to avoid fried food. Low-fat or nonfat milk is recommended for the patient with CAD. pp. 704-705

A patient presents to the emergency department with chest pain. Which question would the nurse ask first? A. "Where is your discomfort located?" B. "What medications are you taking?" C. "Do you have a history of migraines?" D. "Have you ever worn a Holter monitor?"

Answer: A. "Where is your discomfort located?" Rationale: "Where is your discomfort located?" addresses the "R" (region) of the "PQRST" pneumonic for angina assessment and helps determine which type of angina the patient is experiencing. The nurse should ask this first to determine how best to proceed. "What medications are you taking?" is important in getting the patient's medical history, but the nurse can ask this question once he or she has better determined the nature of the angina. A history of migraines is often seen in patients with Prinzmetal's angina, which occurs at rest; this is also a lower-priority question. "Have you ever worn a Holter monitor?" most likely will reveal any possible ischemia if the patient has worn one, but this is not a priority assessment. p. 708

Which individuals would the nurse identify as having the highest risk for coronary artery disease (CAD)? A. A 45-year-old male with depression and a high-stress job B. A 60-year-old male with below-normal homocysteine levels C. A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) levels D. A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) or 23 kg/m2

Answer: A. A 45-year-old male with depression and a high-stress job Rationale: The 45-year-old depressed male with a high-stress job is at the highest risk for CAD. Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight. The patient with two risk factors is at greatest frisk for developing CAD. p. 700

The nurse receives information about the assigned patients during shift report. Which patient would the nurse assess first? A. A patient who reports a severe headache and has begun vomiting. B. A patient who reports dizziness with a BP of 150/92 mm Hg C. A patient with a hip fracture who reports a pain level of 2 on a 1-to-10 scale D. A patient who received an angiotensin-converting enzyme (ACE) inhibitor 30 minutes previously and reports fatigue

Answer: A. A patient who reports a severe headache and has begun vomiting Rationale: Severe headache and vomiting are signs of a hypertensive crisis, which is an emergency situation; therefore the nurse must assess this patient first. Dizziness is one of the symptoms of hypertension, and the patient has an elevated BP, but it is not an emergency situation. A pain level of 2 on a scale of 1 to 10 is mild pain, and therefore this patient is not a priority. Fatigue is one of the symptoms of hypertension, but the patient just received an antihypertensive medication. p. 695

A patient being treated for acute decompensated heart failure (ADHF) presents with intractable cough. The nurse reviews the patient's medication profile and suspects that which drug is related to the assessment finding? Med profile: Nitrate, ACE inhibitor, Aldosterone antagonist, beta-blocker, diuretic, probiotic A. Angiotensin-converting enzyme (ACE) inhibitor B. Aldosterone antagonist C. Beta-Blocker D. Nitrate

Answer: A. Angiotensin-converting enzyme (ACE) inhibitor Rationale: Major side effects of ACE inhibitors include symptomatic hypotension, intractable cough, hyperkalemia, angioedema (allergic reaction involving edema of the face and airways), and renal insufficiency (when used in high doses). An intractable cough is defined as a cough of more than a 3-week duration. The assessment finding is not related to use of an aldosterone antagonist, a beta-blocker, or a nitrate. p. 745

A patient on a cardiac unit is shivering. Which finding would the nurse expect to see on the patient's electrocardiogram (ECG) tracing? A. Artifact B. Asystole C. Atrial flutter D. Junctional dysrhythmia

Answer: A. Artifact Rationale: An artifact is a distortion of the baseline and waveforms seen on the ECG. If the patient is shivering or shows any muscle activity, accurate interpretation of the heart rhythm is difficult, and artifacts can occur on the monitor. Asystole is the absence of all cardiac electrical activity. Atrial flutter occurs in chronic lung disease or hypertension. Junctional dysrhythmias are associated with an electrolyte imbalance or rheumatic heart disease. p. 757

A patient's BP increases from 110/76 mm Hg to 160/90 mm Hg two hours after a surgical procedure. Which action would the nurse take first? A. Assess pain level. B. Reassess the BP in 15 minutes. C. Decrease the IV fluid rate. D. Restart the patient's antihypertensive medication.

Answer: A. Assess pain level Rationale: Treatment for hypertension focuses on the source of the problem. Pain often causes a rise in BP. If a patient becomes hypertensive, the nurse should begin with assessing and treating the pain. Reassessing the BP in 15 minutes would not be done first but after treating the patient for pain. Per prescription of the health care provider, decreasing the IV fluid and administering an antihypertensive medication may be appropriate but are not the first nursing interventions. p. 338

A patient's electrocardiogram (ECG) has changed from a normal sinus rhythm to the following rhythm. The patient is sleeping, respirations are 16 breaths/min and unlabored, and the BP has dropped from 110/70 mm Hg to 104/68 mm Hg. Which action would the nurse take? A. Continue monitoring the patient. B. Perform an in-depth assessment. C. Notify the health care provider. D. Check the medical record for hyperkalemia.

Answer: A. Continue monitoring the patient. Rationale: Sinus bradycardia can be a normal finding for athletes or patients when they sleep. Sinus bradycardia becomes clinically significant if the patient is symptomatic (hypotensive, chest pain, shortness of breath, change of level of consciousness). Because the respiratory status of the patient is stable and the BP is only slightly lower because the patient is sleeping, the nurse should continue monitoring the patient. Hyperkalemia is characterized by a peaked T wave, and in advanced stages a widened QRS complex, neither of which are demonstrated on this ECG tracing. p. 760

A patient experiences an acute aortic dissection. Which medication may be given to lower the patient's heart rate of a beta-blocker is contraindicated? A. Diltiazem B. Morphine C. Reloxifene D. Epoetin alfa

Answer: A. Diltiazem Rationale: The initial goal in treating aortic dissection is to maintain the heart rate and BP to prevent stress on the aortic wall. Beta-adrenergic blockers and calcium channel blockers reduce stress on the aortic wall by decreasing systolic BP and myocardial contractility. Calcium channel blockers such as diltiazem should be administered if beta-blockers are contraindicated. Morphine reduces pain. Raloxifene is used to prevent osteoporosis. Epoetin alfa is used to stimulate erythropoiesis. p. 813

A patient who has undergone hemodialysis experiences profuse bleeding at the access site. The nurse suspects which cause of the increased bleeding? A. Heparin treatment B. Scratching the access site C. Increase in BP D. Infection at the access site

Answer: A. Heparin treatment Rationale: Bleeding is a common complication of hemodialysis due to heparinization. Clotting problems, dialysis membrane rupture, and high doses of heparin cause bleeding problems. Scratching the access site, increased BP, and infection at the access site will not cause profuse bleeding. p. 1079

Which clinical manifestation of acute kidney injury may cause changes in an electrocardiogram (ECG)? A. Hyperkalemia B. Fluid overload C. Hyponatremia D. Metabolic acidosis

Answer: A. Hyperkalemia Rationale: Acute or rapid development of hyperkalemia affects the heart and causes ECG changes, such as peaked T waves, widening of the QRS complex, and ST-segment depression. Fluid overload may lead to pulmonary edema and heart failure. Uncontrolled hyponatremia may lead to the development of cerebral edema. Metabolic acidosis causes Kussmaul respirations. p. 1062

While caring for a patient, the nurse observes indications of warfarin toxicity. Which medication would the nurse expect to be prescribed? A. Vitamin K B. Lepirudin C. Protamine D. Argatroban

Answer: A. Vitamin K Rationale: Vitamin K is an antidote for warfarin toxicity. Lepirudin, protamine, and argatroban do not reverse the anticoagulant properties of warfarin. Lepirudin, a hirudin derivative, is an anticoagulant. Protamine is an antidote for unfactionated heparin (UH). Argatroban, a synthetic thrombin inhibitor, is also an anticoagulant. p. 817

The nurse is preparing an initial care plan for a patient who presents with chest pain. Which is the priority nursing intervention? A. Monitoring the patient's cardiac rhythm B. Discussing the losses associated with chronic illness C. Encouraging verbalization of feelings, perceptions, and fears D. Advising the patient to avoid heavy meals and extreme weather conditions

Answer: A. Monitoring the patient's cardiac rhythm Rationale: A patient with chest pain may have acute coronary syndrome. The priority is to stabilize the patient, determine the plan of care, and prevent complications. Ongoing care should include continuous electrocardiogram (ECG) monitoring. The nurse should help the patient with anxiety and stress to work on the losses due to chronic illness to prevent sudden depression related cardiac workload, but that is not the highest priority. A patient with chronic stable angina is advised to avoid heavy melas and extreme weather to reduce the probability of symptoms, and this may be appropriate to teach at a later time. The nurse should encourage verbalization of feelings, perceptions, and fears that increases workload on heart but that is not a higher priority than monitoring for life-threatening dysrhythmias. pp. 708, 720

A patient with a heart rate of 180 beats/minute has a regular heart rhythm, normal P waves, and normal PR intervals. Which QRS complex shape would the nurse expect to see on the patient's electrocardiogram (ECG) tracing? A. Normal B. Not measurable C. Wide and distorted D. Abnormally shaped

Answer: A. Normal Rationale: A normal P wave and normal PR interval in ECG and the heart rate of 180 beats/minute indicates sinus tachycardia. The patient with sinus tachycardia general shows normal QRS complexes. The QRS complex will not be measurable in the patient with ventricular fibrillation. The QRS complex will be wide and distorted or abnormally shaped in the ECG of a patient who has ventricular tachycardia or premature ventricular contractions. The P wave in these patients will not usually be visible, and the PR interval will not be measurable. p. 760

A patient with a history of unstable angina reports a sudden onset of retrosternal chest heaviness and tightness, fatigue, shortness of breath, and nausea. Which actions would the nurse take? Select all that apply. A. Obtain a 12-lead electrocardiogram (ECG). B. Administer sublingual nitroglycerin. C. Place the patient in a supine position. D. Apply high-flow oxygen by face mask. E. Auscultate for a pericardial friction rub.

Answer: A. Obtain a 12-lead electrocardiogram (ECG). B. Administer sublingual nitroglycerin. Rationale: Initial management of the patient with chest pain includes the following: Obtain a 12-lead ECG and start continuous ECG monitoring. Position the patient in an upright, not supine, position unless contraindicated, and initiate oxygen by nasal cannula (not high-flow by face mask) to keep oxygen saturation above 93%. Establish an IV route to provide an access for emergency drug therapy. Give sublingual nitroglycerin and aspirin (chewable). Morphine sulfate is given for pain unrelieved by nitroglycerin (NTG). Auscultating for a pericardial friction rub is not an appropriate action. p. 722

Which characteristic is typical of the pain related to chronic stable angina? A. Relieved by rest, nitroglycerin, or both B. Indicates irreversible myocardial damage C. Generally lasts longer than 15 to 20 minutes D. Frequently associated with vomiting and fatigue

Answer: A. Relieved by rest, nitroglycerin, or both Rationale: Chronic stable angina is characterized by intermittent chest pain, often described as pressure or tightness that occurs over a period of time in the same pattern, onset, and intensity. It commonly subsides when precipitating factors have stopped and the patient is at rest or with the use of nitroglycerin. The pain does not always indicate irreversible myocardial damage and usually lasts just 5 to 15 minutes. Vomiting and extreme fatigue are symptoms of myocardial infarction and are not commonly seen in chronic stable angina. p. 709

Which electrolytes play key roles in polarization of the heart cells? A. Sodium and potassium B. Potassium and calcium C. Potassium and glucose D. Sodium and magnesium

Answer: A. Sodium and potassium Rationale: The electrolytes sodium and potassium are partners in cardiac function. A higher sodium level outside the cell allows for a high potassium and low sodium level inside the cell. Potassium inside the cell is required for the conduction of impulses to achieve a polarized state.

Which type of angina increases in frequency, duration, and severity over time? A. Unstable angina B. Prinzmetal's angina C. Microvascular angina D. Chronic stable angina

Answer: A. Unstable angina Rationale: Unstable angina increases in frequency, duration, and severity as the time progresses. Prinzmetal's angina occurs primarily at rest and is triggered by smoking and increased levels of substances, such as histamine and epinephrine. Microvascular angina is triggered by activities of daily life and exertion. Chronic stable angina is provoked by exertion and relieved by by rest. p. 717

A patient's history includes an ejection fraction of 30%, diabetes, reports of stabbing chest pain that is relieved upon rest, and prescription for catopril. If the patient is intolerant of catopril, which medication would the nurse expect will be prescribed? A. Valsartan B. Tirofiban C. Everolimus D. Carvedilol

Answer: A. Valsartan Rationale: A patient with an ejection fraction of 30%, diabetes mellitus, and angina has a cardiovascular risk. The patient who is intolerant of angiotensin-converting enzyme (ACE) inhibitor should receive an angiotensin II receptor blocker such as valsartan. Tirofiban is a glycoprotein IIb/IIIa inhibitor that is used to prevent the abrupt closure of the stents during percutaneous coronary intervention (PCI). Everolimus prevents the overgrowth of new intimacy that leads to stent restenosis. Carvedilol is a beta-blocker that carries cautions for its use in a patient with diabetes because it masks the signs of hypoglycemia. p. 713

Which time period does the T wave in an electrocardiogram (ECG) represent? A. Ventricular repolarization B. Depolarization of both ventricles C. Passage of the electrical impulse through the atrium D. Time between ventricular depolarization and repolarization

Answer: A. Ventricular repolarization Rationale: The ECG is commonly used to detect abnormal heart rhythms and to investigate the cause of chest pains. The T wave in the ECG should be upright; it represents time for ventricular repolarization. Time taken for depolarization of both ventricles is represented by QRS interval. Time for the passage of the electrical impulse through the atrium is represented by P wave. Time between ventricular depolarization and depolarization is represented by ST segment. p. 758

A patient who is scheduled for an abdominal aortic aneurysm (AAA) repair surgery takes warfarin daily. Which medication would the nurse expect to administer preoperatively? A. Vitamin K B. Cobalamin C. Heparin sodium D. Protamine sulfate

Answer: A. Vitamin K Rationale: Warfarin is a vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin. Cobalamin is vitamin B12 and is not an antidote for warfarin. Protamine sulfate is the antidote for heparin sodium. Heparin sodium is an anticoagulant and not an antidote for warfarin. p. 817

Which question would the nurse ask the older patient regarding risk factors for coronary artery disease (CAD)? A. What us your body mass index (BMI) number? B. Did you receive a pneumococcal vaccine? C. When did you last have a bowel movement? D. Did you travel abroad within the last 12 months?

Answer: A. What is your body mass index (BMI) number? Rationale: Risk for CAD increases with obesity, which is defined as a BMI of more than 30 kg/m2. Constipation is not a risk factor for CAD. Traveling abroad to underdeveloped countries is a risk factor for infectious disease but not for CAD. Pneumococcal vaccine protects the elderly patient from pneumonia but not from CAD. p. 702

The community health nurse is planning health promotion teaching to prevent coronary artery disease (CAD). Which population has the highest incidence of CAD? A. White male B. Hispanic male C. Black male D. Native American female

Answer: A. White male Rationale: The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or blacks. Blacks have an earlier age of onset and more severe CAD than whites and more than twice the mortality rate of whites of the same age. Native Americans have increased mortality in 35-year-old and under people have major modifiable risk factors, such as diabetes. p. 700

Which statement by a patient diagnosed with chronic stable angina indicates understanding of the disease process? A. "Angina is caused by spasms within a coronary blood vessel." B. "Anginal pain is caused by an increased demand or a decreased supply of oxygen." C. "Angina is causing an irreversible damage to my cardiac muscles by cardiac ischemia." D. "Anginal symptoms start when atherosclerosis completely occludes a coronary artery."

Answer: B. "Anginal pain is caused by an increased demand or a decreased supply of oxygen." Rationale: A mismatch between oxygen demand of cardiac muscles and supply of oxygen leads to myocardial ischemia, which is manifested as pain. Prinzmetal's angina is caused by coronary vasospasm. Myocardial ischemia is completely reversible. The patient will start to experience symptoms of ischemia when the coronary artery is blocked by 75% or more.

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

Answer: B. "I can take up to 5 tablets every 3 minutes for relief of my chest pain." Rationale: The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after five minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every five minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely. Nitroglycerin degrades over time and should be replaced every six months. Acetaminophen is useful for headaches caused by nitroglycerin. Patients with chronic angina are taught to take nitroglycerin in anticipation of an activity that usually causes pain. p. 711

A patient states, "I have episodes of sharp and stabbing chest pain that last 10 minutes when I am restocking shelves at work." The patient is diagnosed with chronic stable angina. Which instruction would the nurse give to the patient to prevent anginal pain while at work? A. "Perform 30 minutes of moderate exercise before going to work." B. "Take nitroglycerin (NTG) 5 to 10 minutes before restocking the shelves." C. "Take a dose of the medication 30 minutes after restocking the shelves." D. "Take NTG every 5 minutes during the task until the work is complete."

Answer: B. "Take nitroglycerin (NTG) 5 to 10 minutes before restocking the shelves." Rationale: Reports of 10 minutes of a sharp, stabbing pain when performing strenuous work indicate that the patient is experiencing an attack of chronic stable angina. The patient should be advised to take NTG prophylactically, 5 to 10 minutes before engaging in the activity. Patients with Prinzmetal's angina may get relief from chest pain by performing moderate exercise. Taking the medication after the activity will not prevent the pain. The maximum number of NTG tablets the patient can take is three. p. 711

A preoperative patient asks why the dose of warfarin is being withheld? Which response by the nurse is most accurate? A. "This medication is contraindicated with the type of anesthesia you are receiving." B. "This medication could cause excessive bleeding during surgery if it is not stopped beforehand." C. "All unnecessary medications are stopped before surgery to prevent you from vomiting under anesthesia." D. "This medication may increase respiratory depression associated with anesthetic agents and must be avoided."

Answer: B. "This medication could cause excessive bleeding during surgery if it is not stopped beforehand." Rationale: Warfarin is an anticoagulant that could caused excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, the patient's clotting parameters are monitored as a means of ensuring that the effects of the medication are reversed. Warfarin is not associated with respiratory depression and does not interact with anesthesia. Medications are held before surgery' the most correct and complete reason for holding this medication is related to the increased risk of bleeding during and following surgery. p. 302

A patient with varicose veins has been prescribed compression stockings. Which information should the nurse provide to the patient? A. "Try to keep your stockings on 24 hours a day, as much as possible." B. "While you're still lying in bed in the morning, put on your stockings." C. "Dangle your feet at your bedside for five minutes before putting on your stockings." D. "Your stockings will be most effective if you remove them for a few minutes every four hours."

Answer: B. "While you're still lying in bed in the morning, put on your stockings." Rationale: The patient with varicose veins should apply stockings in bed before rising in the morning. Stockings should not be worn continuously, but they should not be removed every four hours. Dangling feet at the bedside before application of stockings is likely to decrease their effectiveness. p. 823

The health care provider at the clinic prescribes lisinopril for four patients newly diagnosed with hypertension. The nurse anticipates which patient may not respond as well to this medication? A. A 68-year-old Asian female B. A 45-year-old African American male C. A 70-year-old male of European descent D. A 53-year-old female of European descent

Answer: B. A 45-year-old African American male Rationale: Genetic differences among different groups of people may help predict how the body will process a medication. The nurse anticipates that the 45-year-old African American male may not respond as well to the angiotensin-converting enzyme (ACE) inhibitor compared to those of European or Asian descent, who statistically respond better to this class of drugs. p. 27

A patient is at risk for developing a deep vein thrombosis after a knee replacement surgery. Which intervention reduces the risk of this complication? A. Applying heat to the operative site B. Administering prophylactic anticoagulant drugs C. Providing intermittent positive pressure ventilation D. Restricting the range of motion of the unaffected lower extremity

Answer: B. Administering prophylactic anticoagulant drugs Rationale: To decrease the risk for thromboembolism after knee replacement surgery, a patient is treated with prophylactic anticoagulant drugs. Heat is applied during the initial postoperative period to decrease swelling. However, heat does not affect the development of a deep vein thrombosis. Intermittent positive pressure ventilation is administered during fat embolism syndrome. Restricting the range of motion of the unaffected lower extremity would result in thromboembolism. p. 1474

The health care provider prescribed warfarin for a patient with venous thromboembolism (VTE). Which information would the nurse include in the patient's discharge teaching plan? A. No routine laboratory monitoring is needed. B. Avoid contact sports and high-risk activities. C. Increase daily intake of dark-green, leafy vegetables. D. Continue to use garlic as a dietary supplement.

Answer: B. Avoid contact sports and high risk activities. Rationale: Teaching for a patient prescribed warfarin includes avoiding any trauma or injury that might cause bleeding, such as contact sports. Routine laboratory monitoring is needed to assess the therapeutic effect of the medication and whether a change in frug dose is needed. Do not increase daily intake of dark-green, leafy vegetables because these foods are high in vitamin K. Garlic may affect blood clotting. Instruct the patient to consult with the health care provider about the use of garlic supplements along with warfarin. p. 821

A patient with a history of asthma presents to the emergency department with wheezing, chest pain, and shortness of breath. Which type of medication listed in the patient's medication profile may be responsible for the patient's symptoms? A. short-acting nitrate B. Beta-adrenergic blocker C. Calcium channel blocker D. Angiotensin II receptor blocker

Answer: B. Beta-adrenergic blocker Rationale: The patient with a history of asthma should avoid beta-adrenergic blockers because the side effects include wheezing from bronchospasm. Short-acting nitrates are the first-line treatment for a patient with angina and can be used safely by patients who have asthma. Calcium channel blockers are used in patients who have asthma if beta-blockers are contraindicated, poorly tolerated, or do not control anginal symptoms. Angiotensin II receptor blockers can be given to the patient safely because they have no harmful effects on the respiratory system. p. 714

Which mechanism of action makes atenolol beneficial to a patient with hypertension? A. Activates dopamine receptors B. Blocks beta-adrenergic receptors C. Relaxes arterial and venous smooth muscles D. Reduces conversion of angiotensin 1 to angiotensin 2

Answer: B. Blocks beta-adrenergic receptors Rationale: Atenolol is a cardioselective beta-adrenergic receptor blocker (beta-blocker) that reduces BP. It also reduces cardiac output and reduces sympathetic vasoconstrictor tone. It also decreases renin secretion by the kindeys. Fenoldopam, a direct vasodilator, activates dopamine receptors, resulting in systemic and renal vasodilation. Nitroglycerin is a direct vasodilator, in which relaxes arterial and venous smooth muscle, reducing preload and systemic vascular resistance (SVR). Angiotensin-converting enzyme (ACE) inhibitors inhibit ACE, reducing the conversion of angiotensin 1 to angiotensin 2. p. 680

Which laboratory result increases a patient's risk for coronary artery disease (CAD)? A. Decreased triglycerides B. Elevated low-density lipoproteins (LDLs) C. Elevated high-density lipoproteins (HDLs) D. Decreased very-low-density lipoproteins (VDLs)

Answer: B. Elevated low-density lipoproteins (LDLs) Rationale: Elevated LDLs contain more cholesterol than any of the other lipoproteins and have an affinity for arterial walls. Elevated LDL levels correlate most closely with an increased incidence of atherosclerosis and CAD. Elevated HDLs, decreased triglycerides, and decreased VLDLs are all negative risk factors for CAD. p. 700

The nurse reviews the medical records of four patients. Which information indicates a patient's high risk for venous thromboembolism? A. Hyperuricemia B. Hormone therapy C. Anticoagulant therapy D. High C-reactive protein levels

Answer: B. Hormone therapy Rationale: Venous thromboembolism is a condition associated with both deep vein thrombosis (DVT) and pulmonary embolism (PE) in a patient. Hormone therapy decreases clotting factors (such as fibrinogen, protein S, protein C, tissue factor pathway inhibitor [TFPI], and antithrombin), which increases the risk of venous thromboembolism. Hyperuricemia (excess uric acid in the blood) increases risk for developing peripheral artery disease. Receiving anticoagulant therapy increases the risk of bleeding. High C-reactive protein levels increase risk for peripheral artery disease. p. 820

Which action does the T wave in a patient's electrocardiogram (ECG) represent? A. Depolarization of the atria B. Repolarization of the ventricles C. Repolarization of the Purkinje fibers D. Delayed repolarization in hypokalemia

Answer: B. Repolarization of the ventricles Rationale: On an ECG, the T wave represents depolarization of the ventricles. Depolarization of the atria is represented by the P wave. The U wave, if present, can represent either depolarization of the Purkinje fibers or hypokalemia. p. 657

Which instruction is important for the nurse to provide to a patient about the management of stage 1 hypertension? A. Restrict all caffeine. B. Restrict sodium intake. C. Increase protein intake. D. Use calcium supplements.

Answer: B. Restrict sodium intake Rationale: The patient should decrease the intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Caffeine and protein intake do not affect hypertension. Calcium supplements are not recommended to lower BP. p. 686

Which behaviors can help reduce psychologic risk factors that contribute to the development of coronary artery disease (CAD)? Select all that apply. A. Monitoring glucose levels daily B. Setting realistic goals for exercise C. Changing eating patterns and habits D. Planning time for adequate rest and sleep E. Increasing activities to a prescribed fitness level F. Learning effective stress management techniques

Answer: B. Setting realistic goals for exercise D. Planning time for adequate rest and sleep F. Learning effective stress management techniques Rationale: Setting realistic goals for exercise increases psychologic well-being because reaching attainable goals can help boost the patient's level of confidence. Planning time for adequate rest and sleep contributes to the patient's psychologic well-being, which can reduce the risk for development of CAD. Learning effective stress management techniques helps to reduce the risk for development of CAD by helping the patient better manage stress levels. Increasing activities to a prescribed fitness level, monitoring glucose levels daily, and managing eating patterns and habits are all appropriate behaviors to aid in the reduction of risk factors for CAD, but they address physiologic, not psychologic, components. p. 704

A patient's electrocardiogram (ECG) shows a heart rate of 150 beats/minute and a normal P wave preceding each QRS complex. Which interpretation would the nurse make of these findings? A. Atrial fibrillation B. Sinus tachycardia C. Ventricular fibrillation D. Premature atrial contractions

Answer: B. Sinus tachycardia Rationale: Sinus tachycardia includes a heart rate of 101 beats to 180 beats per minute. The electrocardiographic study of sinus tachycardia shows a normal P wave preceding each QRS complex with normal time and duration. In atrial fibrillation, the P waves are chaotic and fibrillary and the QRS complex is normal. The electrocardiographic study of ventricular fibrillation elicits the absence of P waves, and the PR interval and QRS interval cannot be measured. In premature atrial contraction, there are distorted P waves in the ECG. p. 760

A patient undergoing treatment for dysrhythmia is provided with a Holter monitor. Which information would the nurse include in the patient teaching about the test? Select all that apply. A. The patient should activate the monitor when experiencing symptoms. B. The patient should record activities and any symptoms in a diary. C. The monitor records the electrocardiogram (ECG) when the patient is ambulatory. D. New technology using smart phone apps can obtain and save ECG recordings. E. The monitor records the ECG when the patient performs daily activities.

Answer: B. The patient should record activities and any symptoms in a diary. C. The monitor records the electrocardiogram (ECG) when the patient is ambulatory. D. New technology using smart phone apps can obtain and save ECG recordings. E. The monitor records the ECG when the patient performs daily activities. Rationale: The patient should keep a diary and record activities and any symptoms. The Holter monitor continuously records the ECG while the patient is ambulatory and performing daily activities. New technology using smart phone apps can obtain and save ECG recordings and even detect some dysrhythmias. The patient would not wait to activate the monitor when having symptoms, which the Holter monitor records continuously. Event monitors are activated only when having symptoms. p. 760

The nurse provides information to a patient about ways to decrease risk factors for coronary artery disease (CAD). Which statement by the patient indicates understanding of the teaching? A. "I will add weightlifting to my daily exercise program." B. "I will change my diet to increase my intake o saturated fats." C. "I will change my lifestyle to alter patterns and decrease my stress." D. "I need to switch to smokeless tobacco instead of smoking cigarettes."

Answer: C. "I will change my lifestyle to alter patterns and decrease my stress." Rationale: Health-promoting behaviors for those at risk for CAD include altering patterns that are conductive to stress. Other ways to promote health include physical activity, such as brisk walking (3-4 mph for at least 30 minutes 5 or more times a week), reducing total fat and saturated fat intake, and stopping all tobacco use. pp. 701-702, 704

A patient is admitted to the hospital with chronic stable angina. Which information would the nurse teach the patient about pain associated with the diagnosis? A. "The pain typically occurs at rest and usually lasts more than 10 minutes." B. "The pain is triggered by activities of daily living; therefore such activities will need to be limited." C. "The pain may last for a few minutes and stop when the precipitating factor is resolved." D. The pain is triggered by smoking; therefore a smoking cessation program will be recommended."

Answer: C. "The pain may last for a few minutes and stop when the precipitating factor is resolved."

Which assessment finding would the nurse expect when caring for a patient with superficial vein thrombosis? A. Presence of edema with pain B. Induration of the overlying muscle C. Appearance of the vein as a palpable cord D. Tenderness to pressure over the involved vein

Answer: C. Appearance of the vein as a palpable cord Rationale: In superficial vein thrombosis, the vein appears as a palpable cord. Edema rarely occurs in superficial vein thrombosis. Induration of overlying muscle, tenderness to palpation over the involved vein, and presence of edema with pain are noted in venous thromboembolism. p. 814

A patient is diagnosed with venous thromboembolism. Which assessment finding would the nurse expect? A. Abnormal capillary refill B. Unusually warm extremities C. Asymmetry in limb circumference D. Pitting edema of lower extremities

Answer: C. Asymmetry in limb circumference Rationale: Venous thrombosis is the formation of clots and most commonly occurs in the pelvis or lower extremity- that is, in the deep veins of the legs. This condition results in asymmetry in limb circumference. Possible reduced arterial capillary perfusion and anemia cause abnormal capillary refill. Throtoxicosis results in unusually warm extremities. Interruption of venous return to the heart and right-sided heart failure are associated with pitting edema of the lower extremities. p. 665

A patient with angina is prescribed a calcium channel blocker. Upon reviewing the medication history, the nurse finds that the patient is on digoxin. For which complication would the nurse monitor? A. Increase in weight B. Prolonged QT interval C. Decrease in BP D. Increased serum digoxin level

Answer: D. Increased serum digoxin level Rationale: The nurse should closely monitor the serum digoxin levels for toxicity because calcium channel blockers potentiate the action of digoxin by increasing serum digoxin levels. Weight should be monitored in patients taking beta-blockers. QT wave prolongation should be monitored upon administration of sodium current inhibitors. Long-acting nitrates, such as isosorbide dinitrate and isosorbide mononitrate, can cause hypotension, resulting in orthostatic hypotension. p. 714

The nurse is caring for a patient with acute pulmonary embolism (PE) and expects that which subcutaneous medication will be included in the patient's treatment plan? A. Warfarin B. Alteplase C. Enoxaparin D. Tissue plasminogen activator

Answer: C. Enoxaparin Rationale: Subcutaneous administration of low-molecular-weight heparin (LMWH) (e.g., enoxaparin [Lovenox], frogmen [Dalteparin], or fondaparinux) is the recommended treatment for patients with acute PE. LMWH is safer and more effective than unfractionated heparin. Warfarin (Coumadin) is an oral anticoagulant; it is started at the time of diagnosis. Warfarin should be given for at least three months and then reevaluated. Direct thrombin inhibitors are given IV; some health care providers use them in the treatment of PE. The fibrinolytic agents, such as tissue plasminogen activator (tPA) or alteplase (Activase), may help dissolve the PE and the source of the thrombus in the pelvis or deep leg veins, thereby decreasing the risk for recurrent emboli. p. 534

A 78-year-old patient has a diagnosis of hypertension with a cholesterol level of 250 mg/dL and a fasting triglyceride level of 195 mg/dL. Which level of risk does this patient have for coronary artery disease (CAD)? A. None B. Low C. High D. Unable to determine

Answer: C. High Rationale: Increasing age is a non modifiable risk factor for coronary artery disease. Hypertension is the second major risk factor in CAD. The risk of CAD is associated with a serum cholesterol level greater than 200 mg/dL or a fasting triglyceride level greater than 150 mg/dL. This patient has several risk factors for CAD and is therefore considered high risk. The patient has too many risk factors to be considered low or at no risk, and additional information is not necessary to determine high risk. p. 700

Which intervention would the nurse implement while administering heparin sodium to a patient? A. Aspirating while administering the medication B. Rubbing the site after administering the medication C. Rotating the medication administration site frequently D. Using the IM route for medication administration.

Answer: C. Rotating the medication administration site frequently Rationale: Rotating the injection site while administering heparin sodium prevents tissue trauma and reduces pain. The nurse should avoid aspiration while administering heparin sodium to prevent tissue damage and hematoma formation. The nurse should avoid rubbing the site after administering heparin sodium to prevent hematoma formation in the patient. Heparin sodium should be administered by subcutaneous route to ensure effective therapeutic drug action. p. 817

An increase in the rate of cardiac impulse initiation is linked to stimulation of which component? A. Purkinje system B. Electrolyte system C. Sympathetic nervous system D. Parasympathetic nervous system

Answer: C. Sympathetic nervous system Rationale: The sympathetic nervous system is responsible for increasing the rate of cardiac impulse initiation at the SA node. It also assists with node impulse conduction and cardiac contractility.

Which statement describes the electrical activity represented by the PR interval on an electrocardiogram (ECG)? A. The length of time it takes to depolarize the atrium. B. The length of time it takes for the atria to depolarize and repolarize. C. The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers D. The length of time it takes for the electrical impulse to travel from the SA node to the atrioventricular (AV) node

Answer: C. The length of time for the electrical impulse to travel from the sinoatrial (SA) node to the Purkinje fibers. Rationale: The electrical impulse in the heart must travel from the SA node through the AV bode and into the Purkinje fibers for synchronous atrial and ventricular contraction to occur. When measuring the PR interval (the time from the beginning of the P wave to the beginning of the QRS), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node through the atrium, causing depolarization of the atria (atrial contraction). Atrial repolarization occurs during ventricular depolarization and is hidden by the QRS complex. The length of time it takes for the electrical impulse to travel from the SA node to the AV node is the flat line between the end of the P wave and the beginning of the Q wave on the ECG and is not usually measured. p. 758

The nurse is performing an assessment on a patient who presented to the emergency department with a report of chest pain. Which assessment data would indicate that the patient has stable angina? A. The patient developed chest pain shortly after going to bed. B. The patient developed chest pain while sitting and reading a book. C. The pain developed when the patient was jogging and subsided after the patient rested. D. The pain starts approximately the same time every day without regard to activity level.

Answer: C. The pain developed when the patient was jogging and subsided after the patient rested. Rationale: Pain associated with stable angina is precipitated by increased demand of myocardial muscle for oxygen that happens with exercising or other activity and subsides with rest in 5 to 15 minutes. Nocturnal angina occurs when patient is supine in bed. Prinzmetal's angina (variant angina) occurs at rest. Prinzmetal's angina (variant angina) is characterized by pain that occurs at the same time of the day. p. 708

Which explanation would the nurse give to a postoperative patient who is reluctant to get up and walk? A. "Early walking keeps your legs limber and strong." B. "Early ambulation will help you be ready to go home." C. "Early ambulation will help you get rid of your syncope and pain." D. "Early walking is the best way to prevent postoperative complications."

Answer: D. "Early walking is the best way to prevent postoperative complications." Rationale: The best rationale is that early ambulation will prevent postoperative complications that then can be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and venous thromboembolism (VTE), speeds wound healing, increases vital capacity, and maintains normal respiratory function. These things help the patient to be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management always should occur before walking. p. 337

Which is a disadvantage of centralized monitoring system? A. It cannot diagnose dysrhythmias B. It measures the patients' heart rate remotely. C. It cannot rapidly detect myocardial ischemia. D. It requires continuous observation of patients' electrocardiograms (ECGs).

Answer: D. It requires continuous observation of patients' electrocardiograms (ECGs). Rationale: A centralized monitoring system is a type of telemetry monitoring system. It requires continuous observation of a group of patients' electrocardiograms at a central location. Centralized monitoring systems observe heart rate and rhythm remotely, at a site distant from the patient. A centralized monitoring system helps to detect dysrhythmias, ischemia, or infarction in patients. p. 757

The nurse is teaching a patient with chronic stable angina about the use of nitroglycerin (NTG). Which statement by the patient indicates effective learning? A. "I should dissolve the tablets in a glass of water." B. "I should replace the tablets in the container every 18 months." C. "I should store the medication in a pocket to have it readily available." D. "I should take a tablet five minutes before an activity that is known to cause angina."

Answer: D. "I should take a tablet five minutes before an activity that is known to cause angina." Rationale: NTG is a first-line treatment for patients with chronic stable angina. The patient should take NTG 5 to 10 minutes before beginning activities that are known to cause angina pain. The tablets are to be placed under the tongue, not dissolved in water. The patient should keep NTG tablets away from light and heat sources, including body heat, to protect them from degradation. After the container has been opened, the patient should replace the tablets in the container every six months. p. 711

An adult patient with no medical history is being seen in a clinic for a routine physical exam. The patient's BP reading is 158/92. The patient asks the nurse: "Does this mean that I have hypertension?" Which response would the nurse provide? A. "Do not worry. Everything is fine." B. "It is a normal BP reading for an adult." C. "Yes, you have hypertension because your BP is over 140/90." D. "You need a follow-up BP check to make that determination."

Answer: D. "You need a follow-up BP check to make that determination." Rationale: A diagnosis of hypertension will not be made based on one elevated BP reading. Considering the fact that the patient does not have any medical problems and that this reading is the first elevated BP reading, a follow-up office visit is required. Providing false reassurance to the patient is leading to misinformation. Normal BP is defined as a systolic BP (SBP) of less than 120 mm Hg and a diastolic BP (DBP) of less than 80 mm Hg, so a reading of 158/92 is not normal. p. 681

A patient has a two-month history of taking warfarin as treatment for deep vein thrombosis (DVT). The patient is scheduled for an unrelated surgery. Which international normalized ratio (INR) result indicates that the patient will likely require vitamin K before surgery? A. 1.0 B. 1.2 C. 2.0 D. 3.4

Answer: D. 3.4 Rationale: Vitamin K is the antidote to warfarin. Warfarin is an anticoagulant that impairs the ability of the blood to clot; therefore it is necessary to give vitamin K before surgery to reduce the risk of hemorrhage. The value of the INR indicates an impairment of clotting ability, making 3.4 the correct selection. For a patient with a history of venous thromboembolism (VTE), a therapeutic INR is maintained between 2.0 and 3.0. p. 818

When prescribed an angiotensin-converting enzyme (ACE) inhibitor, which potential side effect would affect the patient's lower urinary tract function? A. Polyuria B. Bladder irritation C. Urinary retention in males D. Cough triggering stress urinary incontinence (UI)

Answer: D. Cough triggering stress urinary incontinence (UI) Rationale: ACE inhibitors in chronic dry cough leading to stress UI. Alcohol and diuretics cause polyuria. Methylxanthines cause bladder irritation. Alpha-adrenergic receptor agonists cause urinary retention in males. p. 1047

A patient has been prescribed atenolol. Which condition should the nurse question the patient about before administering the drug? A. Asthma B. Dry cough C. Depression D. Diabetes mellitus

Answer: D. Diabetes Mellitus Rationale: Atenolol is a cardioselective Beta-1 blocker that reduces BP by blocking beta-adrenergic effects. It should be used with caution in patients with diabetes mellitus because it depresses the tachycardia associated with hypoglycemia and may hinder diagnosing hypoglycemia. A history of asthma, dry cough, or depression does not affect the administration of the drug. Noncardioselective beta-adrenergic receptor blockers (beta-blockers) should not be used in patients with asthma because of the risk of bronchospasm, but this is not the case with atenolol because it is cardioselective. Angiotensin-converting enzymes may cause a dry cough. Reserpine should not be administered in patients with depression because this may cause the condition to worsen. p. 687

A patient recently diagnosed with coronary artery disease (CAD) asks the nurse: "What caused my problem?" Which cause would the nurse explain? A. Orthostatic hypotension B. Low oxygen saturation of the blood C. The heart's inability to pump effectively D. Fatty deposits on the walls of the coronary arteries

Answer: D. Fatty deposits on the walls of the coronary arteries Rationale: The major cause of CAD is atherosclerosis, which is manifested by fatty deposits on the walls of coronary arteries. Decrease in pumping action of the heart will result in congestive heart failure (CHF). Low oxygen saturation of the blood is a result of respiratory problems. Hypertension, not orthostatic hypotension, will predispose a patient to developing CAD. p. 699

The nurse recalls that heparin should not be given to a patient with a history of which condition? A. Splenomegaly B. Thromboembolism C. Hepatic encephalopathy D. Heparin-induced thrombocytopenia (HIT)

Answer: D. Heparin-induced thrombocytopenia (HIT) Rationale: With HIT, heparin causes decreased platelet counts and increases the risk for hemorrhage. Patients who have had HIT should never be given heparin or low-molecular-weight heparin (LMWH). This should be clearly marked in the patient's medical record. Splenomegaly is an enlarged spleen; this often occurs with anemia and autoimmune disorders. Thromboembolism is another term for blood clot; heparin is used to treat clots and would not cause them. Hepatic encephalopathy occurs in alcoholic patients when brain tissue is destroyed due to decreased thiamine. p. 622-623

A patient's BP reading is 142/91 mm Hg. How should the nurse classify the BP? A. Normal B. Prehypertension C. Hypertension, stage 1 D. Hypertension, stage 2

Answer: D. Hypertension, stage 2 Rationale: Normal BP is defined as a systolic BP (SBP) of less than 120 mm Hg and a diastolic BP (DBP) of less than 80 mm Hg. Elevated BP is defined as an SBP between 120 and 129 mm Hg and a DBP of less than 80 mm Hg. Hypertension (stage 1) is defined as an SBP between 130 and 139 mm Hg and a DBP between 80 and 89 mm Hg. Hypertension (stage 2) is defined as an SBP of greater than 140 mm Hg and a DBP of greater than 90 mm Hg. If either the SBP or DBP is outside a range, the higher measurement determines the classification. p. 681

The BP of a 71-year-old patient admitted with pneumonia is 160/70 mm Hg. Which age-related change contributes to this finding. A. Stenosis of the heart valves B. Decreased adrenergic sensitivity C. Increased parasympathetic activity D. Loss of elasticity in arterial vessels

Answer: D. Loss of elasticity in arterial vessels Rationale: An age-related change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because of the increasing resistance to flow, pressure is increased within the blood vessel, and hypertension results. The valvular rigidity of aging causes murmurs, and decreased adrenergic sensitivity slows the heart rate. BP is not raised. Increased parasympathetic activity would slow the heart rate. p. 661

A patient tells the nurse, "Recently, each time I run on a treadmill machine, I get chest pain. The pain goes away when I rest." Which medication is likely to be prescribed for use before the patient exercises? A. Atenolol B. Diltiazem C. Morphine D. Nitroglycerin

Answer: D. Nitroglycerin Rationale: Nitroglycerin (NTG) causes vasodilation, which decreases the blood volume returned to the heart and the resistance of the heart pump, causing a decrease in oxygen demand and consumption. Patient can use NTG prophylactically before starting an activity that is known to cause angina. Atenolol is a beta-blocker that lowers pulse and BP. Diltiazem is used to treat hypertension, not exercise-induced angina. Morphine produces venous dilation, reduces oxygen demand, and decreases pain and respirations. p. 711

Which patient is at the highest risk of developing coronary artery disease (CAD)? A. Patient A: 43-year-old nonsmoking black female B. Patient B: 26-year-old Hispanic male who smokes one pack of cigarettes per day C. Patient C: 64-year-old Caucasian male with a BP of 119/78 mm Hg D. Patient D: 56-year-old black female with a cholesterol level of 300 mg/dL

Answer: D. Patient D: 56-year-old black female with a cholesterol level of 300 mg/dL

Which observation on a patient's telemetry electrocardiogram (ECG) monitor is a cause for concern? A. Upright P wave B. Flat ST segment C. Upright T wave D. Prolonged QT interval

Answer: D. Prolonged QT interval Rationale: Prolonged QT interval is cause for concern. QT disturbance may be caused by drugs, electrolyte imbalances, and changes in heart rate. Upright P wave, flat ST segment, and upright T wave are normal findings. p. 769

A patient who is receiving heparin therapy manifests signs of heparin overdose. Which medication would the nurse anticipate administering? A. Lepirudin B. Rituximab C. Prednisone D. Protamine sulfate

Answer: D. Protamine sulfate Rationale: Protamine sulfate reverses the anticoagulant effects of circulating heparin during severe clotting. Lepirudin is given to maintain anticoagulation. Rituximab is given to reduce the immune recognition of platelets. Prednisone is used to suppress the phagocytic response of splenic macrophages. p. 625

Which waveform in the electrocardiogram (ECG) tracing would be distorted when a patient has an electrolyte imbalance? A. P wave B. Q wave C. S wave D. T wave

Answer: D. T wave Rationale: The T wave represents ventricular repolarization in an ECG. Disturbances (e.g., tall, peaked, inverted) in T waves can occur due to electrolyte imbalances, ischemia, and infarction. Disturbances in the P wave can be due to alterations in atrial conduction. Disturbances in the Q wave can occur due to myocardial infraction. Disturbances in the S wave do not affect the normal functioning of heart. p. 758

Which intervention would the nurse include in the care of a patient who has chronic venous insufficiency (CVI)? A. Application of topical antibiotics to venous ulcers B. Administering oral or subcutaneous anticoagulants C. Maintaining the patient's legs in a dependent position D. Teaching the patient the correct use of compression stockings

Answer: D. Teaching the patient the correct use of compression stockings Rationale: CVI requires conscientious and consistent application of compression stockings. Antibiotics, if required, are typically oral or IV, not topical. Anticoagulants are not necessarily indicated. The patient should avoid prolonged positioning with the limb in a dependent position. p. 823

A patient is prescribed warfarin following a deep venous thrombosis and pulmonary embolism. Which information would the nurse include in the teaching plan? Select all that apply. A. Eliminate green vegetables from the diet. B. Do not take ibuprofen or aspirin unless prescribed. C. Use a soft toothbrush and observe the gums for bleeding. D. Wear a bracelet that identifies that the patient is taking an anticoagulant. E. Blood coagulation testing is needed only for the first four to six weeks of therapy.

Answer: B. Do not take ibuprofen or aspirin unless prescribed. C. Use a soft toothbrush and observe the gums for bleeding. D. Wear a bracelet that identifies that the patient is taking an anticoagulant. Rationale: Warfarin acts as an anticoagulant by inhibiting liver production of vitamin K. Patients are at risk for bleeding and should use a soft toothbrush. Wearing an identification bracelet will alert emergency medical personnel in case the patient is unable to inform them about the medication. Nonsteroidal anti-inflammatory drugs, including aspirin, potentiate the anticoagulation effect and may cause problems with bleeding. Green vegetables, which are sources of vitamin K, should be taken in consistent amounts but need not be eliminated. The patient taking warfarin will continue to need coagulation laboratory testing (prothrombin time/internationalized normal ratio [INR]) while taking the medication because the anticoagulation effect is influenced by many factors, including medications and diet. pp. 818, 820

A nurse provides education to a patient with hypertension related to lifestyle modifications to reduce overall cardiovascular risk. Which statement made by the patient indicates effective learning? Select all that apply. A. "I should exercise for at least 30 minutes daily. B. "I should achieve and maintain a healthy weight." C. "I should limit my alcohol intake to five drinks per day." D. "I should restrict my salt intake to less than or equal to 1500 mg/day." E. "I can continue to smoke because nicotine does not affect BP."

Answers: A. "I should exercise for at least 30 minutes daily." B. "I should achieve and maintain a healthy weight." D. "I should restrict my salt intake to less than or equal to 1500 mg/day." Rationale: Lifestyle modifications play a vital role in reducing BP and cardiovascular risk. Overweight people are at higher risk of cardiovascular disease. A weight loss of 22 lb may decrease systolic BP by approximately 5 to 20 mm Hg. Being physically active is essential to maintaining good health. It decreases the cardiovascular risk of hypertension. Sodium reduction helps to control BP. A patient with hypertension should lower salt intake to 1500 mg/day. The nicotine in tobacco causes vasoconstriction and increases BP. Therefore smokers who are hypertensive should stop smoking. Excessive alcohol consumption increases the risk of hypertension. Consuming three or more drinks per day increases the risk of cardiovascular disease and stroke. p. 685

A patient being treated for peripheral vascular disease reports erectile dysfunction (ED). Which medication classifications listed in the patient's health record may be contributing to the condition? Select all that apply. A. Diuretics B. Phosphodiesterase (PDE) inhibitors C. Beta-Adrenergic receptor blockers (beta-blockers) D. Corticosteroids E. Antidepressants

Answers: A. Diuretics C. Beta-Adrenergic receptor blockers (beta-blockers) Rationale: Beta-blockers, which are used to treat cardiovascular disorders, have ED as a major side effect. Taking diuretics along with medications for peripheral vascular disease increases problems in sexual function, such as decreased libido and difficulty ejaculating. PDEs such as sildenafil (Viagra) are often the first-line therapy for ED, not the cause of it. Oral antidepressants do not directly cause ED in patients with peripheral vascular disease, although they may contribute to decreased libido. Corticosteroids help reduce breathing difficulty but do not impair sexual activity. p. 663

The nurse provides education to a patient about the symptoms of uncontrolled hypertension. Which symptoms would the nurse include? Select all that apply. A. Fatigue B. Dizziness C. Palpitations D. Cluster headaches E. Shortness of breath

Answers: A. Fatigue B. Dizziness C. Palpitations E. Shortness of breath Rationale: A patient with severe hypertension may have a variety of symptoms secondary to the effects on blood vessels in the various organs and tissues or to the increased workload of the heart. These secondary symptoms include fatigue, dizziness, palpitations, angina, and dyspnea. Cluster headaches do bot occur with uncontrolled hypertension. p. 682

Which information in a patient's admission history may be the cause of the patient's sinus bradycardia? Select all that apply. A. Hypothermia B. Hyperglycemia C. Hyperthyroidism D. Calcium channel blockers E. Increased intracranial pressure

Answers: A. Hypothermia D. Calcium channel blockers E. Increased intracranial pressure Rationale: The possible causes of sinus bradycardia include hypothermia, treatment with calcium channel blockers, and increased intracranial pressure. Hypothermia may cause reduced venous return, thereby causing bradycardia. Calcium channel blockers cause bradycardia by decreasing automaticity of the SA node and delaying the AV node conduction. The drug also reduces myocardial contractility. Increased intracranial pressure may suppress the cardia centers in the brain thus reducing the heart rate. Hyperglycemia causes tachycardia by causing systemic dehydration and acidosis. Hyperthyroidism increases the levels of thyroid hormone and increases the metabolism resulting in tachycardia. p. 760

A patient admitted to the health care facility with venous thromboembolism (VTE) is prescribed unfractionated heparin, to be administered subcutaneously. Which technique would the nurse use when administering the medication? Select all that apply. A. Inject deep into abdominal fatty tissue. B. Hold skin fold during injection. C. Release skin fold after removing needle. D. Avoid aspiration. E. Rub site after injection.

Answers: A. Inject deep into abdominal fatty tissue. B. Hold skin fold during injection. D. Avoid aspiration. Rationale: When administering unfractionated heparin subcutaneously, the nurse should inject deep into the abdominal fatty tissue, hold the skinfold during injection but release before removing the needle, and avoid aspiration. The nurse should not inject IM, rub the site after injection, or aspirate. p. 817

Which actions will decrease the likelihood of a patient developing varicose veins? Select all that apply. A. Maintaining ideal body weight B. Avoiding long periods of sitting C. Taking 325 mg of aspirin daily D. Applying hydrating lotions to the skin of legs daily. E. Avoid standing for long periods

Answers: A. Maintaining ideal body weight B. Avoid long periods of sitting E. Avoid standing for long periods Rationale: Varicose veins are dilated, tortuous veins that occur mainly in the legs. Family history is thought to be a factor in the development of incompetent valves in the leg veins that become varicose veins. Strategies that promote competent veins in the legs include walking, avoiding standing and sitting for long periods of time, and keeping an ideal body weight. Aspirin therapy will not prevent varicose veins. Hydrating lotions will condition the skin but not prevent varicose veins. p. 823

Which electrocardiogram (ECG) characteristics would the nurse use to interpret that a patient is in normal sinus rhythm (NSR)? Select all that apply. A. The R-R intervals are relatively consistent. B. One P wave precedes each QRS complex. C. Four to five complexes occur in a six-second strip. D. The ST segment is higher than PR interval. E. The T wave is upright.

Answers: A. The R-R intervals are relatively consistent. B. One P wave precedes each QRS complex. E. The T wave is upright. Rationale: The consistency of the R-R interval indicates regular rhythm. A normal P wave before each complex indicates that the impulse originated in the SA node. The T wave is upright and represents ventricular repolarization. The number of complexes in a six-second strip is multiplied by 10 to approximate the heart rate; therefore a normal heart rate (60 to 100) is six to ten complexes in a six-second strip. Four to five complexes in a six-second strip would calculate to a heart rate of 50 to 50, which is bradycardia. An elevation of the ST segment is a sign of cardiac ischemia and is not a characteristic of NSR. p. 760

Which conditions are possible causes of the artifact in a patient's electrocardiogram (ECG) tracing? Select all that apply. A. The patient is shivering. B. The patient has dry skin. C. The conductive gel is moist. D. Electrical interference is present. E. The leads and electrodes are not secure.

Answers: A. The patient is shivering. D. Electrical interference is present. E. The leads and electrons are not secure. Rationale: Muscle activity caused by shivering of the patient, electrical interference, or loose leads and electrodes can cause distorted baseline and waveforms called an artifact on the ECG. Oily skin is wiped dry with alcohol to prepare the patient for ECG. Electrodes may have to be replaced if conductive gel has dried out. p. 757

The nurse is examining a female patient who experiences leg edema and pain. Which history findings indicate that the patient is at high risk for venous thromboembolism (VTE)? Select all that apply. A. The patient uses tobacco. B. The patient lives in a high-altitude area. C. The patient has a family history of VTE. D. The patient has been taking aspirin daily for one year. E. The patient takes an estrogen-based oral contraceptive.

Answers: A. The patient uses tobacco. B. The patient lives in a high-altitude area. C. The patient has a family history of VTE. E. The patient takes an estrogen-based oral contraceptive. Rationale: A Oman who uses tobacco is at high risk for VTE. High altitude causes hyper coagulability of blood. The risk increases if the patient has a family history of VTE because the patient may carry the mutated genes responsible for the disease. A woman who uses an estrogen-based oral contraceptive is at high risk for VTE. These compounds may cause hyper coagulability and may activate the intrinsic coagulation pathway that leads to deep vein thrombosis and pulmonary embolism. Aspirin inhibits platelet aggregation and decreases risk for clotting. p. 814

Which indications of deep venous thromboembolism (VTE) would the nurse monitor in a postoperative patient? Select all that apply. A. Venous distention B. Vein appearing as a palpable cord C. Deep reddish color over the affected area D. Itchiness and warmth over the affected area E. Tenderness with palpation

Answers: A. Venous distention C. Deep reddish color over the affected area E. Tenderness with palpation Rationale: Clinical findings for VTE include tenderness to pressure over involved vein, induration of overlying muscle, venous distention, edema, possible mild to moderate pain, and a deep reddish color to area caused by venous congestion. Itchiness and cordlike texture are characteristics of superficial venous thrombosis. p. 814

When teaching strategies would the nurse use when teaching a patient how to measure BP at home? Select all that apply. A. Provide a booklet on hypertension. B. Demonstrate the technique to the patient. C. Explain the need to measure BP. D. Use medical terminology when speaking to the patient. E. Ask the patient to repeat the action without the nurse's help.

Answers: B. Demonstrate the technique to the patient. C. Explain the need to measure BP. E. Ask the patient to repeat the action without the nurse's help. Rationale: Teaching of physical skills such as taking a BP should include demonstration and re-demonstration. Adult learners need to understand the reason for learning a new skill; the nurse will explain the purpose of home BP monitoring. Since the goal of the teaching is that the patient can take the BP at home, a booklet on hypertension would not be included in this instruction (although a booklet about hypertension would be appropriate to include when teaching about risks of elevated BP). Since patients may not understand medical terminology, it is best to use simple and short explanations and avoid medical terminology. pp. 46, 52-54

A patient who has prosthetic heart valves is being treated with warfarin to prevent blood clots. Which dietary supplements would the nurse teach the patient to avoid? Select all that apply. A. Soy B. Garlic C. Fish oil D. Melatonin E. Red yeast rice

Answers: B. Garlic C. Fish oil D. Melatonin Rationale: Many dietary supplements have adverse interactions with drugs and increase the risk of complications. Garlic, fish oil, and melatonin tend to increase the risk of bleeding and should be avoided in patients who are taking warfarin (Coumadin). Soy is used to treat high cholesterol. Red yeast rice is used to treat high cholesterol levels. pp. 818, 820

A nurse working in a burn unit would identify which patients are at an increased risk of developing venous thromboembolism? Select all that apply. A. Young age B. Morbid obesity C. Prolonged immobility D. Upper-extremity burns E. First-degree burn of a finger

Answers: B. Morbid obesity C. Prolonged immobility Rationale: The risk factors for the development of venous thromboembolism in a burn patient are morbid obesity and prolonged immobility. These patients may develop stasis of blood due to immobility, which results in development of venous thromboembolism. Young age is not a risk factor for venous thromboembolism; rather, old age predisposes a person to venous thromboembolism. Usually, lower-extremity burns are risk factors for venous thromboembolism because they cause stagnation of blood. First-degree burn of a finger is not an extensive burn and hence is not a risk factor for venous thromboembolism. p. 439

A patient with spinal cord injury is suspected of having venous thromboembolism (VTE). Low-molecular-weight heparin is prescribed. Before initiating the drug, the nurse performs which assessments? Select all that apply. A. Gastroenteritis B. Signs of infection C. Signs of any internal bleeding D. Any history of recent surgeries E. Signs of any respiratory distress

Answers: C. Signs of any internal bleeding D. Any history of recent surgeries Rationale: Low-molecular-weight heparin (e.g., enoxaparin) is used to prevent VTE unless contraindicated. Contraindications include internal bleeding and recent surgery. Low-weight heparin can be administered in the presence of any infection, respiratory problems, or gastroenteritis. p. 1410

The nurse reviews the admission history of patient who is hospitalized with deep vein thrombosis (VTE) in the left leg. Which findings from the health history increased the risk for the patient to develop this complication? Select all that apply. Medical History: *Gastroesophageal reflux disease 3 years *Osteoarthritis 10 years *Dyslipidemia * Has never smoked cigarettes Surgical History: *Abdominal hysterectomy 10 years ago *Left knee joint replacement 2 weeks earlier Medications at Home: *Omeprazole *Conjugated estrogen *Simvastatin A. Take simvastatin regularly B. Takes omeprazole regularly C. Takes conjugated estrogen regularly D. Negative history for cigarette smoking E. Left knee replacement two weeks prior to the current hospitalization F. Abdominal hysterectomy 10 years prior to the current hospitalization

Answers: C. Takes conjugated estrogen regularly E. Left knee replacement two weeks prior to the current hospitalization Rationale: Estrogen, a hormone used for relief of menopausal discomfort, increases clotting factors and enhances coagulation. The risk for developing thromboembolic complications continues for several weeks postoperatively. The risk is related to possible vascular injury with the procedure, altered fluid status, increased coagulability, and lessened mobility during and after surgery. The recent left knee joint replacement surgery is significant. Medications such as lipid-lowering agents (simvastatin) and proton pump inhibitors (omeprazole) do not increase the risk for thrombosis. The patient does not smoke, thereby avoiding the risk factor of smoking. The abdominal hysterectomy performed 10 years earlier is not a current risk factor. p. 815

Match the property of the cardiac conduction system with its description. A. Property of the cell that allows it to accept initiation of stimulation B. Property that moves electrical impulse along a membrane C. Ability of heart muscle to respond mechanically to an impulse D. Ability of heart muscle to initiate an impulse, begin stimulation

Answers: (Matched) A. Excitability B. Conductivity C. Contractility D. Automaticity

The nurse is teaching a patient about the common side effects of antihypertensive medications. Which information would the nurse include? Select all that apply. A. Sexual problems B. Resistant hypertension C. Orthostatic hypotension D. Frequent voiding and dry mouth from diuretics E. Rebound hypotension if the drug is stopped abruptly

Answers: A. Sexual problems C. Orthostatic hypotension D. Frequent voiding and dry mouth from diuretics Rationale: Reduced libido or erectile dysfunction are examples of sexual problems as a side effect of antihypertensive medications. Alteration of the autonomic nervous system mechanism by antihypertensive medications leads to orthostatic hypotension. Diuretics are one class of medications for the treatment of hypertension that cause frequent urination and dry mouth. "Resistant hypertension" is a term used to describe a failure to reach the desired BP in the patient who takes multiple antihypertensive medications. Rebound hypertension results from an abrupt stopping of antihypertensive medication use. p.690