med #3

Notify the physician immediately

A patient who presented to the emergency room with a myocardial infarction (MI) becomes pale, diaphoretic, and hypotensive. What action should the nurse take first?

* Proteins * Folic acid * Iron

A patient with a nutritional anemia may lack which nutrients? (Select all that apply.)

"The valves in the vessels in your legs aren't working as well as they used to, which causes the discoloration and thickening of your skin."

An 86-year-old patient asks why her ankles have a brownish discoloration and the skin looks thick. Which response best addresses the patient's concern?

30 minutes

Blood infusions must be started within how many minutes of its arrival on the unit?

* The patient experiences complete heart block * The patient's pulse rate remains below 40 beats/min

During the acute phase following a myocardial infarction (MI), the nurse anticipates that the patient may require a temporary pacemaker in which situation(s)? (Select all that apply.)

An MI causes myocardial necrosis

How does a myocardial infarction (MI) alter the pumping efficiency of the heart?

Every 2 to 3 months

How often should a patient with polycythemia vera have phlebotomy to thin the blood?

Pressure in the relaxed ventricles

In a blood pressure of 120/80, what does the "80" indicate?

Hemoglobin

Iron deficiency anemia impacts adequate production of which component?

"You sound a little down. Tell me what you think is going to keep you from those activities; we might be able to address the problems."

The 60-year-old female in the post-coronary care unit confides to the nurse, "My life is over. I'll never be able to care for my family, take a vacation, or work in my garden." Which response is most supportive?

Claudication

The 65-year-old patient complains of leg pain that disappears at rest after having walked a short distance. The nurse recognizes that the patient's symptoms are consistent with which problem?

Insufficient valves

The 85-year-old patient with a newly diagnosed heart murmur expresses concern that he has never been notified of this finding before. What is the most likely cause of this patient's heart murmur?

"Alteplase (t-PA) dissolves the obstruction in the coronary artery."

The drug alteplase (t-PA) is given to the patient with a myocardial infarction (MI). Which statement accurately describes the purpose of this medication?

"It tastes better when I take my medicine with milk."

The home health nurse is caring for a patient who is taking ferrous sulfate (Feosol). Which statement indicates that the patient requires additional teaching about this medication?

Hypertensive crisis

The home health nurse is caring for a patient with a blood pressure reading of 200/160. The patient denies any discomfort. The nurse should immediately contact the health care provider to report that the patient is experiencing which problem?

A 3 pound weight gain over the course of a week

The home health nurse is caring for a patient with congestive heart failure (CHF). Which assessment finding should the nurse report immediately to the physician?

Maintenance of high fluid intake

The home health nurse is caring for a patient with polycythemia vera. Which focus is most important for the nurse to emphasize?

Pericarditis

The nurse assesses a friction rub in a patient who is 2 days post-myocardial infarction (MI). The nurse recognizes this finding indicates which problem?

Hypotension

The nurse caring for a patient who is taking amiodarone (Cordarone). What side effect could this patient experience?

"I may experience uncomfortable muscle contractions."

The nurse caring for a patient who requires a temporary transvenous pacemaker. Which statement indicates that the patient understands the nurse's teaching?

* Aspirin * Morphine * Nitrates * Oxygen

The nurse clarifies that the MONA protocol for drug administration in the emergent stage of a myocardial infarction (MI) involves the use of which therapies? (Select all that apply.)

* Nutritional counseling * Supervised progressive exercise * Stress reduction techniques

The nurse encourages the patient who has had a myocardial infarction (MI) to enroll in the outpatient cardiac rehabilitation in order to receive which service(s)? (Select all that apply.)

Limit the patient's activity Weigh the patient daily

The nurse in a skilled nursing facility is caring for an 80-year-old patient who develops a productive cough with pink, frothy sputum. Which independent interventions should the nurse implement immediately? (Select all that apply.)

* Exertion * Emotional excitement * Eating heavy meals * Exposure to cold

The nurse instructs a patient that the pain of angina is due to ischemia of the myocardium. Which factors are causative agents for angina? (Select all that apply.)

Atrial flutter

The nurse is analyzing a patient's telemetry strip and observes a sawtooth appearance with no P waves. How should the nurse document this finding?

"I stay tired all of the time, and it feels like my bra is too tight."

The nurse is assessing a female patient with a family history of coronary artery disease (CAD). Which report is most concerning to the nurse?

* Gums * Roof of the mouth

The nurse is assessing a patient with a dark complexion for cyanosis. To ensure the most accurate assessment, which locations should the nurse inspect? (Select all that apply.)

Blood pressure (BP) of 100/60

The nurse is assessing a patient with polycythemia vera. Which finding is consistent with this disorder?

* Electrocardiographic (ECG) changes in the QRS complex * Elevation of troponin levels

The nurse is aware that a positive diagnosis of a myocardial infarction (MI) is based on which diagnostic test finding(s)? (Select all that apply.)

The trait can be passed on to all children

The nurse is caring for a 20-year-old female patient with sickle cell trait. Which statement accurately reflects this patient's condition?

* Race * Diabetes * Use of oral contraceptives

The nurse is caring for a 38-year-old African American patient with diabetes. The patient manages her diabetes with dietary control, takes oral contraceptives, and is a nonsmoker. Which characteristic(s) in this patient's history increase the patient's risk for coronary artery disease (CAD)? (Select all that apply.)

Shiny, hairless legs

The nurse is caring for a 50-year-old patient who complains of tingling in his toes. Which other assessment finding would cause the nurse to suspect arterial insufficiency?

* Hypertension * Obesity * Smoking

The nurse is caring for a 60-year-old African American patient with hypertension. The patient is obese and a smoker. Which modifiable risk factors place this patient at an increased risk for heart disease? (Select all that apply.)

Cover with clear occlusive dressing

The nurse is caring for a 75-year-old patient with a history of diabetes and peripheral vascular disease (PVD). The nurse observes an inflamed and excoriated area on the patient's right shin. Which intervention should the nurse perform first?

Pernicious anemia

The nurse is caring for a 79-year-old male who underwent a gastrectomy 1 month ago. The nurse recognizes that this patient is at the greatest risk for which type of anemia?

Fatigue

The nurse is caring for a female patient with a family history of heart disease who is undergoing a workup for cardiovascular disease. Which finding is most concerning to the nurse?

Store nitroglycerin tablets in a cool, dark location

The nurse is caring for a male patient with angina who has a new prescription for sublingual nitroglycerin. What information is most important for the nurse to include in the teaching plan?

Troponin of 2.4 mcg/L

The nurse is caring for a patient admitted with chest pain to rule out a myocardial infarction (MI). The nurse observes that the patient is experiencing electrocardiogram (ECG) changes and reviews new laboratory results. Which laboratory value should the nurse report immediately?

Contact the physician immediately

The nurse is caring for a patient diagnosed with an abdominal aortic aneurysm who complains of sudden, intense abdominal pain and light-headedness. What action should the nurse take next?

"This medication lowers blood pressure by blocking an enzyme that causes blood vessels to constrict."

The nurse is caring for a patient on lisinopril (Zestril). The patient asks how this medication affects blood pressure. Which response best explains the medication's effects?

Increase intake of bananas and potatoes

The nurse is caring for a patient who has a new prescription for a loop diuretic. Which nutritional intervention is most important for the nurse to add to the care plan?

"I will have to move extremely quickly from the treadmill to the table."

The nurse is caring for a patient who is scheduled to undergo a stress echocardiogram. Which statement indicates that the nurse's teaching about preparation for the test has been successful?

Blurred vision

The nurse is caring for a patient who is taking digitalis. The patient complains of increased thirst, and the nurse observes dry mucous membranes. Which additional finding warrants the nurse's immediate attention?

Remove the clutter from the patient's room

The nurse is caring for a patient who is taking radiation treatments. The patient has a platelet count of 100,000/mm3. Which action is most important for the nurse to add to the patient's care plan?

The nurse places the pulse oximeter on the thumb or first digit of the affected hand

The nurse is caring for a patient who just returned from a transradial heart catheterization. Which action indicates the priority care for the postprocedure period?

The nurse places the pulse oximeter on the thumb or first digit of the affected hand.

The nurse is caring for a patient who just returned from a transradial heart catheterization. Which action indicates the priority care for the postprocedure period?

Encourage increased fluid intake

The nurse is caring for a patient who underwent a transfemoral cardiac catheterization with coronary angiography earlier in the day. The patient denies pain and no longer requires bed rest. The groin is soft with no palpable hematoma. Which postprocedure care is most important for the patient at this time?

"I should walk at least an hour every day for 2 weeks."

The nurse is caring for a patient who underwent endovenous laser treatment. Which statement indicates that the nurse's teaching about postprocedure management has been successful?

An ongoing bacterial infection

The nurse is caring for a patient whose complete blood count reports an abnormal amount of "bands," or immature granulocytes. Based on this finding, which problem does the nurse suspect?

* Wear gloves when handling cold items * Wear insulated socks when working in cool weather. * Attend a smoking program. * Use a heating pad to stay warm.

The nurse is caring for a patient with Raynaud disease who is employed as a construction worker, has hypertension, and smokes one-half to one pack of cigarettes per day. What teaching points should the nurse include in discharge instructions? (Select all that apply.)

50

The nurse is caring for a patient with a blood pressure of 140/90, an apical pulse of 82, and a radial pulse of 76. Which value indicates that the nurse accurately calculated the patient's pulse pressure?

The nurse places a compression dressing over the wound dressing.

The nurse is caring for a patient with a compression dressing. Which action indicates appropriate wound care?

Hemoptysis

The nurse is caring for a patient with a deep venous thrombosis (DVT). Which finding requires the nurse's immediate attention?

Heparin

The nurse is caring for a patient with a deep venous thrombosis (DVT). Which medication would likely be used for initial inpatient treatment?

Decreased cardiac output

The nurse is caring for a patient with a heart rate of 115 beats/min and complaints of shortness of breath. The nurse anticipates that these findings are most likely related which underlying problem?

"Do you use over-the-counter decongestants or diet pills?

The nurse is caring for a patient with a history of hypertension. Which information is most important for the nurse to obtain?

Wheezes are present during lung auscultation

The nurse is caring for a patient with a history of left-sided congestive heart failure (CHF). Which finding leads the nurse to suspect that the patient could be experiencing an acute exacerbation of this condition?

Percutaneous transluminal angioplasty (PTA)

The nurse is caring for a patient with a history of peripheral arterial disease. The patient complains of significant claudication, and findings of an ankle-brachial index are abnormal. The nurse anticipates that this patient will most likely require which type of procedure?

Inadequate blood flow and poor oxygen supply

The nurse is caring for a patient with agina pectoris who asks what happens to make his body experience pain. The nurse explains that pain results from which underlying causative factor?

Chronic kidney disease

The nurse is caring for a patient with anemia who has a past medical history of diabetes, hypertension, chronic kidney disease, and acid reflux. The nurse is aware the patient's anemia is likely related to which condition?

Provide a soft toothbrush and decrease clutter in the room

The nurse is caring for a patient with aplastic anemia. Which actions are most important for the nurse to take?

Warfarin prevents clots from forming in the atria

The nurse is caring for a patient with atrial fibrillation who asks why she needs to take warfarin. Which statement best answers the patient's question?

Alternate rest with activity

The nurse is caring for a patient with congestive heart failure (CHF). Which intervention should the nurse include in the plan of care?

Altered skin integrity related to ulcers on lower extremities

The nurse is caring for a patient with peripheral arterial disease who complains of 3/10 pain in the lower extremities. The nurse observes a 0.5 cm × 1 cm ulcer on the left lower leg, and the lower legs are shiny and hairless bilaterally. The nurse identifies which priority problem statement/nursing diagnosis?

*Loss of elasticity in vessel walls * Atherosclerotic changes in vessels * Sedentary practices * Weakened leg muscles

The nurse is caring for a patient with peripheral vascular disease (PVD). The nurse understands that which age-related changes may cause PVD? (Select all that apply.)

Apply pressure to the site for 5 minutes with an ice pack

The nurse is caring for a patient with pernicious anemia immediately following a bone marrow biopsy of the left posterior iliac crest. Which action should the nurse perform first?

"Morphine has properties that help relieve air hunger in CHF patients."

The nurse is caring for a patient with severe congestive heart failure (CHF) who denies pain and is fearful of taking prescribed morphine. Which explanation best works to alleviate the patient's anxiety about risk of addiction?

Examination for skin breakdown

The nurse is caring for a patient with sickle cell anemia. Based on the underlying pathophysiology of this disorder, the nurse should carefully perform which detailed assessment?

Maintaining adequate fluid intake

The nurse is caring for a patient with sickle cell anemia. Which intervention may best help prevent sickle cell crisis?

"I am planning a trip to Colorado next month."

The nurse is caring for a patient with sickle cell anemia. Which statement indicates that the patient requires further instruction?

Edema

The nurse is caring for a patient with suspected right-sided heart failure. Which manifestation best supports this potential diagnosis?

Uncontrolled hypertension

The nurse is caring for a patient with uncontrolled hypertension, diabetes, asthma, and gastroesophageal reflux disease (GERD). Which problem serves as a contraindication for a thrombolytic agent?

"I should call my doctor if I experience unexplained muscle pain."

The nurse is caring for a post-myocardial infarction (MI) patient who has been started on daily simvastatin (Zocor) and a low-fat diet. Which statement best indicates that the nurse's teaching has been successful?

"Stool softeners help me keep from straining during bowel movements, which can lower my heart rate."

The nurse is caring for a post-myocardial infarction (MI) patient. The patient questions the reason for a stool softener and denies constipation. Which statement indicates that the patient accurately understands the nurse's teaching?

* Apply light blankets over legs while sitting * Elevate legs frequently * Encourage walking * Maintain a warm environment

The nurse is caring for an 80-year-old long-resident in a term care facility. Which intervention(s) should the nurse plan to enhance blood flow? (Select all that apply.)

Hypoxia

The nurse is caring for an older adult patient who is confused and irritable. The nurse reviews the patient's history and notes that it is negative for dementia. Which potential underlying problem should the nurse suspect?

"Bone marrow activity decreases by about 50% with aging, which lowers the immune response to infection."

The nurse is caring for an older adult patient. A family member of the patient seems to frequently catch colds. Which response is best?

Loss of cells in the sinoatrial (SA) nodes

The nurse is caring for an older adult patient. While auscultating the patient's apical pulse, the nurse notices an irregular rhythm. The nurse suspects which causative factor for the patient's dysrhythmia?

* Liver * Lima beans * Prune juice * Dried apricots

The nurse is caring for patient with iron deficiency anemia. The nurse should encourage intake of which food(s)? (Select all that apply.)

86-year-old with a history of atherosclerosis

The nurse is caring for several patients on a cardiac care unit. Which patient is most likely to have aortic stenosis?

Women should incorporate stress reduction techniques into their daily lifestyle

The nurse is educating a female patient with a family history of coronary artery disease (CAD) about risk factors and prevention of heart disease in women. Which information is most important for the nurse to include?

Women should incorporate stress reduction techniques into their daily lifestyle.

The nurse is educating a female patient with a family history of coronary artery disease (CAD) about risk factors and prevention of heart disease in women. Which information is most important for the nurse to include?

* Systemic hypertension * Chronic excessive alcohol consumption * Pregnancy * Systemic infection

The nurse is educating a patient about cardiomyopathy. The nurse includes information that which circumstance(s) may increase risk for cardiomyopathy? (Select all that apply.)

"Replace a serving of red meat with a serving of fish."

The nurse is educating a patient on a low-fat, low-cholesterol diet after a myocardial infarction (MI). Which food choice should the nurse recommend?

Sit on the side of the bed before standing

The nurse is educating an older adult patient who is taking antihypertensives with diuretics. Which information regarding safety precautions is most important for the nurse to include?

Unstable angina occurs unpredictably, even in sleep

The nurse is explaining the difference between exertional angina and unstable angina. Which statement about unstable angina is accurate?

* Headache * Back pain * Report of a rash * Fever

The nurse is monitoring a patient who is receiving a blood transfusion. Which finding(s) would lead the nurse to stop the infusion? (Select all that apply.)

Keep blood sugar below 100 mg/dL

The nurse is outlining a teaching program for diabetic patients. Which teaching point about heart disease prevention should the nurse emphasize most?

Keep blood sugar below 100 mg/dL.

The nurse is outlining a teaching program for diabetic patients. Which teaching point about heart disease prevention should the nurse emphasize most?

splenomegaly Abdominal distention Dyspnea

The nurse is performing an initial assessment on a new patient with suspected right-sided heart failure. Which finding(s) is/are consistent with the patient's potential diagnosis? (Select all that apply.)

Pale conjunctivae

The nurse is reviewing a patient's assessment data upon admission to the acute care facility. Which finding best indicates iron deficiency anemia?

"The nurses will be able to monitor my heart rate and rhythm."

The nurse is teaching a patient about the purpose of his telemetry. Which statement indicates that the nurse's teaching has been successful?

INR

The nurse is teaching a patient who takes warfarin (Coumadin) about a coagulation monitoring device. Which blood clotting time should the device monitors?

March in place while standing at the counter

The nurse is teaching a pregnant patient who works as a cashier in a grocery store about varicose vein prevention. Which instruction is most important for the nurse to include in the teaching plan?

"I've switched from 5 cups of coffee to 5 cups of tea."

The nurse is teaching the patient with an arrhythmia. Which statement indicates that the patient requires further teaching?

* Palpitations * Dyspnea on exertion

The nurse makes a visual aid differentiating between mild, moderate, and severe anemia. Which signs and symptoms are manifestations of mild anemia? (Select all that apply.)

"It frightens me to think that my heart will be stopped for a long time during surgery."

The nurse performs patient teaching about minimally invasive direct coronary artery bypass (MIDCAB). Which statement indicates that the patient needs further instruction?

"As long as it is okay with your physician, moderate alcohol intake can be beneficial to your cardiovascular health."

The patient asks if it is harmful for him to drink a glass of wine with dinner on a daily basis. Which is the nurse's best response?

"Every patient has different circumstances, but the average 5-year survival rate is 79%."

The patient being evaluated for a heart transplant asks the nurse what the survival rate is. Which response is best for the nurse to make?

Pickles

The patient has been prescribed a low-sodium diet. Which food choice indicates that the patient requires additional teaching?

"You will most likely be able to ambulate within a few hours if your doctor uses an arterial closure device at the catheter insertion site."

The patient states that he had a cardiac catheterization 10 years ago and wonders if any of the postprocedure care has changed. Which response by the nurse is most accurate?

* Observe for melena and hematuria * Measure abdominal girth daily * Apply ice and pressure to puncture sites * Instruct the patient to use an electric razor

The patient with AML has a platelet count of 95,000. What interventions should the nurse include in the patient's care plan? (Select all that apply.)

"The large number of leukemic white cells that you already have are not as effective as normal white cells."

The patient with acute myelogenous leukemia (AML) asks why he is making more WBCs when he already has so many. Which statement clarifies the underlying pathophysiology related to the patient's white blood cells (WBCs)?

Low-dose aspirin helps reduce clotting

The patient with angina asks the nurse how a daily dose of 81 mg of aspirin is helpful. Which reply is best?

"The ICD will detect bad rhythms and shock my heart into normal rhythm."

The statement indicates that the nurse's teaching about the purpose of an implanted cardioverter-defibrillator (ICD) has been successful?

African Americans

The student nurse is planning a community group presentation on hypertension. Which group of individuals should the student identify as having the highest incidence of hypertension?

The student administers 3 mL at the ventrogluteal site

The student nurse is preparing to administer an iron preparation via the intramuscular (IM) route. Which action indicates the need for further instruction?

10 days

What is the average life span of a platelet cell?

Pathologic fractures

When caring for a patient with advanced multiple myeloma, the nursing staff must exercise extreme care to prevent which complication?

3+

When using a 0 to 4+ scale to grade pulse quality, how should the nurse record a normal volume pulse?

* Manage care to include frequent rest periods * Assist with activities of daily living (ADLs) * Place personal care items close at hand * Arrange for small meals with between-meal snacks

Which actions should the nurse take to help the severely anemic patient conserve energy? (Select all that apply.)

* Decreased blood volume * Decreased bone marrow production * Decreased rate of blood cell production * Increased clotting time

Which age-related changes occur in the hematologic system? (Select all that apply.)

* Place marks on the lateral sides of the abdomen where the tape is placed * Use the same tape every day * Measure the same area every day * Measure girth at the same time every day

Which assessment technique assures accuracy in daily abdominal girth measurement? (Select all that apply.)

140/90 × 2, 2 weeks apart

Which blood pressure findings constitute a diagnosis of hypertension?

Hypochromic and microcytic

Which descriptions accurately characterize the appearance of red blood cells (RBCs) in iron deficiency anemia?

* Coarctation of the aorta * Septal defects * Valvular defects

Which disorder(s) is/are examples of congenital heart defects? (Select all that apply.)

Ventricular fibrillation

Which disorganized ECG pattern is recognized as the most fatal of all arrhythmias?

* Hyperkalemia * Valvular prolapse * Infarct damage * Excess fluid

Which factor(s) is/are potential causative agents for arrhythmias? (Select all that apply.)

* Radiation exposure * Pesticides exposure * Benzene exposure

Which factor(s) may be causative for leukemia? (Select all that apply.)

* Stress relief * Diabetes control * Weight control * Routine exercise * Smoking cessation

Which factor(s) may be useful in preventing peripheral vascular disease (PVD)? (Select all that apply.)

Heart rate, preload, afterload, Contraction strength

Which factors may affect the volume of cardiac output? (Select all that apply.)

* Narrowed arteries * Obstructed veins * Defective valve function * Thrombophlebitis

Which findings characterize peripheral vascular disease (PVD)? (Select all that apply.)

* Garlic * Oatmeal * Soy products

Which herbs and supplements lower cholesterol? (Select all that apply.)

* Elevate feet to reduce edema * Apply elastic compression wraps twice daily

Which intervention(s) is/are important for a patient with venous insufficiency? (Select all that apply.)

Myocardium

Which layer of the heart contains muscle fibers that contract to pump blood?

Aspirin

Which medication is the most common and effective antiplatelet aggregation agent?

* Antimetabolite cancer drugs * Phenylbutazone (Butazolidin) * Chloramphenicol (Chloromycetin) * Sulfonamides

Which medication(s) may cause aplastic anemia? (Select all that apply.)

* Smoking * Obesity * Sedentary lifestyle

Which modifiable risk factors increase a patient's risk for heart disease? (Select all that apply.)

* Thymus * Lymph nodes * Spleen

Which organ(s) compose the lymphatic system? (Select all that apply.)

Airport security detection devices

Which potential hazard is most important for a patient with an automatic implantable cardioverter-defibrillator (AICD) to avoid?

* Exercising regularly for at least 30 minutes a day * Maintaining high-density lipoprotein (HDL) greater than 50 mg/dL * Refraining from smoking * Obtaining and maintaining a healthy weight

Which preventative measure(s) may protect against development of cardiovascular disease? (Select all that apply.)

*Stroke * Kidney failure * Heart attack * Congestive heart failure

Which problems are potential complications of uncontrolled hypertension? (Select all that apply.)

"African Americans have the highest incidence of sickle cell disease."

Which statement about the hematologic system is accurate?

Induction therapy is an intensive protocol of chemotherapy in high doses to achieve remission

Which statement accurately describes induction therapy for acute lymphocytic leukemia (ALL)?

To visualize obstructions in leg vessels

Which statement accurately describes the purpose of a Doppler flow study?

The medication inhibits transmission of the impulse from the AV node

Which statement accurately explains how calcium channel blocker verapamil assists to correct an arrhythmia?

* One atrial contraction (P wave) * One ventricular contraction (QRS complex) * One T wave * Heart rate 60 to 100

Which statement(s) accurately describe(s) characteristics of normal sinus rhythm (NSR)? (Select all that apply.)

* To transport blood gases * To regulate pH by buffering * To regulate fluid distribution * To regulate body temperature

Which statement(s) describe functions of blood? (Select all that apply.)

"Avoid lifting heavy objects for as long as your physician prescribes."

Which teaching point will the nurse include when providing discharge instructions to the patient with a new permanent pacemaker?

The nurse uses the bell of the stethoscope while asking the patient to lean forward

While performing a focused cardiac assessment, the nurse auscultates an abnormal swooshing sound. Which action is most appropriate to clarify the nurse's finding?