Med Surg Chapters 23-24

c. Ensure physician is notified immediately.

A healthy postoperative patient who has been on bedrest for 3 days suddenly develops dyspnea, tachypnea, restlessness, and chest pain. The patient says, I feel as if something is going to happen to me. What should the nurse do? a. Perform a bilateral Homans test. b. Give a narcotic for pain as ordered. c. Ensure physician is notified immediately. d. Reassure the patient that everything is fine.

a. Sildenafil (Viagra)

A male patient is prescribed a long-acting nitroglycerin medication for stable angina. Which medication should the nurse remind the patient to avoid while taking the nitroglycerin? a. Sildenafil (Viagra) b. Warfarin (Coumadin) c. Penicillin (Pen-V-K) d. Hydrochlorothiazide (HCTZ)

a. Obtain vital signs.

A patient being treated for an acute MI reports severe chest pressure, as if someone is standing on my chest. What should the nurse do first? a. Obtain vital signs. b. Notify the physician. c. Administer nitroglycerin. d. Order an electrocardiogram.

a. Administer the dose.

A patient being treated for cardiogenic shock has an order for captopril (Capoten). Vital signs are blood pressure 120/70 mm Hg, pulse 85 beats/min, and respirations 16 breaths/min. What action should the nurse take regarding this medication? a. Administer the dose. b. Give the medication 1 hour later. c. Hold the medication and notify the physician. d. Ambulate the patient until blood pressure increases.

d. an embolus

A patient has been diagnosed with thrombus, a patient asks the nurse, "what can be a complication of this condition." The best response by the nurse would be, "you can develop __________." a. an Aneurysm b. a Mitral Valve Prolapse c. PVD d. an embolus

a. Notify the registered nurse (RN) immediately.

A patient has chronic peripheral arterial disease. During neurovascular checks, the nurse finds an absent left pedal pulse and a cyanotic leg. What should the nurse do? a. Notify the registered nurse (RN) immediately. b. Massage the patients left foot. c. Reassess the pulse in 30 minutes. d. Encourage patient to flex the leg 10 times.

a. Chest pain b. Orthopnea c. Heart murmur d. Dyspnea on exertion

A patient is admitted for treatment of aortic stenosis. What findings should the nurse expect when collecting data from this patient? (Select all that apply.) a. Chest pain b. Orthopnea c. Heart murmur d. Dyspnea on exertion e. Oxygen saturation 80%

a. Note any patient shivering. b. Assess breath sounds every shift. c. Assist in head-to-toe data collection. e. Connect the patient to a cardiac monitor. f. Palpate chest and neck for signs of crepitus.

A patient is being admitted to the intensive care unit after cardiac surgery. Which nursing actions should the nurse include in this patients plan of care? (Select all that apply.) a. Note any patient shivering. b. Assess breath sounds every shift. c. Assist in head-to-toe data collection. d. Place the patient in a cool environment. e. Connect the patient to a cardiac monitor. f. Palpate chest and neck for signs of crepitus.

b. Denial

A patient is brought to the emergency room by a daughter who reports that the patient has had multiple episodes of chest pain in the past few days and has refused to seek care. The patient states, I feel fine and the pain has only lasted for brief periods. The nurse recognizes that the patient is most likely using which coping technique? a. Anger b. Denial c. Projection d. Regression

c. Heart failure

A patient is diagnosed with cardiomyopathy. What should the nurse identify as a potential risk for this patient? a. Angina b. Pericarditis c. Heart failure d. Myocardial infarction

d. Surgical valve replacement

A patient is diagnosed with chronic aortic regurgitation. Which procedure should the nurse anticipate being prescribed for this patient? a. Medication therapy b. Valvular annuloplasty c. Valvular commissurotomy d. Surgical valve replacement

b. Right pedal pulse

A patient is recovering from a cardiac catheterization that was completed through the right femoral site. Which information is most essential for the nurse to collect immediately after the procedure? a. Left pedal pulse b. Right pedal pulse c. Left brachial pulse d. Right brachial pulse

a. Antiplatelet

A patient is recovering from stent placement in an occluded coronary artery. Which medication should the nurse expect to be prescribed for this patient? a. Antiplatelet b. Beta blocker c. ACE-Inhibitor d. Calcium channel blocker

a. They are durable c. They create turbulent blood flow.

A patient is scheduled for cardiac surgery for placement of a mechanical valve. Which patient statement indicates correct understanding of characteristics of mechanical valves used for cardiac valve replacement? (Select all that apply.) a. They are durable. b. They require donors. c. They create turbulent blood flow. d. They can be placed during balloon angioplasty. e. They do not require lifelong anticoagulant therapy. f. They may be preferred if anticoagulation is a concern.

d. Eat chicken and fish, keeping red meats to a minimum.

A patient recovering from an MI asks for information about the types of meat that can be eaten. What should the nurse respond to the patient? a. Eat small amounts of any type of meat. b. Eat only vegetables; you do not need to eat meat. c. Eat lean red meat to help increase your iron levels. d. Eat chicken and fish, keeping red meats to a minimum.

b. Splint with a pillow

A patient recovering from cardiac surgery complains of discomfort when turning and moving in bed. What should the nurse encourage the patient perform when making position changes? a. Hold the breath b. Splint with a pillow c. Bend the knees to the chest d. Lift the head off of the bed

a. Notify the RN.

A patient reports acute pain and numbness in the left leg. The nurse notes the left leg is pale and cooler than the right leg. What should the nurse do? a. Notify the RN. b. Elevate the left leg. c. Administer pain medication. d. Apply an extra blanket to the left leg.

a. 8 pm

A patient reports that chest pain started at 2 pm. The nurse realizes that for thrombolytic treatment to be most effective in dissolving a blood clot, it should be given by: a. 8 pm b. 9 pm c. 12 midnight d. 2 am

b. The procedure usually involves removing plaque from the lining of the carotid artery.

A patient scheduled for a carotid endarterectomy asks what is going to happen in the procedure. What should the nurse explain to the patient? a. Procedures are constantly changing, so I dont know what might be planned. b. The procedure usually involves removing plaque from the lining of the carotid artery. c. An endarterectomy is usually done on major vessels of the heart to prevent the need for bypass surgery. d. Typically a catheter is passed through a large vessel in your groin and threaded up into your heart to allow the injection of dye.

a. Notify the RN.

A patient who develops chest pain says the pain is a 9 on a scale of 0 to 10. Which action should the nurse take? a. Notify the RN. b. Apply telemetry. c. Administer aspirin. d. Listen to breathing sounds.

b. Apply oxygen at 2 L/min.

A patient who develops chest pain that radiates down the left arm has all of these measures prescribed. Which one should the nurse do first? a. Repeat vital signs. b. Apply oxygen at 2 L/min. c. Administer nitroglycerin SL. d. Obtain an electrocardiogram (ECG).

a. Obtain vital signs.

A patient who has aortic stenosis develops severe dyspnea and chest pain. What should the nurse do now? a. Obtain vital signs. b. Give nitroglycerin. c. Raise the head of the bed. d. Encourage the patient to sleep.

d. Acute MI

A patient who is apprehensive, gray, cold, and clammy reports pain that is as if an elephant is standing on my chest. The nurse should recognize that these manifestations indicate which health problem? a. Heartburn b. Pericarditis c. An anginal attack d. Acute MI

c. Increased risk of toxicity

A patient who is taking digoxin (Lanoxin) is diagnosed with myocarditis. For which effect should the nurse monitor the patient? a. Increased inflammation b. Decreased inflammation c. Increased risk of toxicity d. Decreased risk of toxicity

a. Notify the registered nurse.

A patient with a deep vein thrombosis receiving a heparin infusion and warfarin (Coumadin) therapy develops bleeding gums. What action should the nurse take? a. Notify the registered nurse. b. Offer the patient a saline mouth rinse. c. Turn off the heparin infusion immediately. d. Tell the patient to gargle with mouthwash.

d. Nitroglycerin SL

A patient with a history of angina has several medications prescribed. Which medication should the nurse administer when the patient reports chest pain? a. Nitropaste b. Aspirin PO c. Digoxin PO d. Nitroglycerin SL

c. If I develop a fever in the next week or so, I need to call my doctor right away.

A patient with a history of mitral valve replacement surgery is instructed to take prophylactic antibiotics before a scheduled root canal. Which patient statement indicates to the nurse that teaching has been effective? a. I know I need to call my doctor if I notice a dry cough. b. If I notice any ankle edema, I should lower my salt intake. c. If I develop a fever in the next week or so, I need to call my doctor right away. d. Endocarditis causes rapid weight gain so I need to weigh myself every day for a full week.

c. Provide anti-inflammatory medication as ordered.

A patient with acute pericarditis has a nursing diagnosis of Pain related to the inflammatory process. What nursing action should the nurse recommend? a. Restrict fluids to 500 mL per day. b. Teach the patient to take shallow, rapid breaths. c. Provide anti-inflammatory medication as ordered. d. Have the patient cough and deep breathe hourly while awake.

2, two 0.25 mg 1 tablet = 2 tablets 0.125 mg

A patient with aortic stenosis experiencing angina and syncope is prescribed 0.25 mg of digoxin (Lanoxin). The nurse has available digoxin, 0.125 mg tablet. How many tablets should the nurse administer to the patient?

b. Digoxin (Lanoxin)

A patient with aortic stenosis is being treated for heart failure. Which medication order should the nurse question? a. Heparin b. Digoxin (Lanoxin) c. Bumetanide (Bumex) d. Warfarin (Coumadin)

a. 30 minutes

A patient with chest pain is a candidate for thrombolytic therapy. How soon should this medication be provided to the patient? a. 30 minutes b. 120 minutes c. 180 minutes d. 240 minutes

d. Decreased cardiac output

A patient with chronic mitral regurgitation states, I am always so tired. Which factor should the nurse identify as contributing to this patients fatigue? a. Coughing b. Heart murmur c. Pulmonary congestion d. Decreased cardiac output

a. Patient reports sudden severe flank pain.

A patient with low back pain is returning from an abdominal computed tomography (CT) scan that revealed an aortic aneurysm. For which finding should the nurse immediately intervene? a. Patient reports sudden severe flank pain. b. Patient BP goes from 144/78 mm Hg to 152/80 mm Hg. c. Patient reports a sense of abdominal fullness after eating. d. Patient informs the nurse of a family history of hypertension.

b. There is backflow of blood into the left atrium.

A patient with mitral regurgitation asks what the health problem means. What should the nurse explain to the patient? a. There is impaired emptying of the left atrium. b. There is backflow of blood into the left atrium. c. There is impaired emptying of the right atrium. d. There is backflow of blood into the right atrium.

c. To prevent a bacterial infection in the heart.

A patient with mitral stenosis is prescribed a preoperative antibiotic. Which patient statement indicates an understanding for taking this medication? a. To prevent postoperative pneumonia. b. To prevent an increase in body temperature. c. To prevent a bacterial infection in the heart. d. To prevent infection of the surgical incision.

a. Eat small meals. b. Drink fluids to remain hydrated. c. Plan activities in small amounts.

A patient with obstructive hypertrophic cardiomyopathy is being released from the hospital and is to continue treatment with atenolol (Tenormin) and disopyramide (Norpace) at home. Which information should be included in the patients teaching plan? (Select all that apply.) a. Eat small meals. b. Drink fluids to remain hydrated. c. Plan activities in small amounts. d. Have one alcoholic drink per day. e. Participate in sports, such as tennis. f. Check the pulse daily before taking medications.

c. Place the patients legs on a tall footstool.

A patient with peripheral venous disease (PVD) is sitting in a chair and has edematous and purple feet. What action should the nurse to take? a. Notify the physician. b. Cover the patient with a blanket. c. Place the patients legs on a tall footstool. d. Have the patient lie in bed with pillow under knees.

c. They are caused by poor function of the valves in your veins.

A patient with varicose veins asks how the condition develops. Which response by the nurse is best? a. Swelling of the vein is caused by bacteria. b. Veins spasm and twist when they get damaged. c. They are caused by poor function of the valves in your veins. d. Veins become blocked by plaque from high-fat diets over time.

c. Pulmonary embolus

A postoperative patient suddenly develops dyspnea, tachypnea, restlessness, and chest pain. Which complication should the nurse suspect is occurring in this patient? a. Pulmonary edema b. Respiratory arrest c. Pulmonary embolus d. Myocardial infarction

c. I need to replace my supply of nitroglycerin every 6 months.

During a home visit, the nurse is reinforcing teaching provided about nitroglycerin therapy. Which patient statement about the supply indicates that teaching has been effective? a. I need to replace my supply of nitroglycerin every 2 months. b. I need to replace my supply of nitroglycerin every 4 months. c. I need to replace my supply of nitroglycerin every 6 months. d. I need to replace my supply of nitroglycerin every 10 months.

a. Notify registered nurse (RN).

During data collection for a patient after cardiac surgery, the nurse notes that chest tube drainage has increased and is now greater than 200 mL per hour. What should the nurse do? a. Notify registered nurse (RN). b. Monitor oxygen saturation. c. Recheck vital signs in 30 minutes. d. Recheck drainage every 30 minutes.

b. The patient has a straight razor on the bathroom sink.

The home health nurse is visiting a patient with cardiomyopathy who lives alone and is prescribed anticoagulant therapy. Which observation indicates that the patient requires more teaching? a. The patient is wearing elastic stockings and slippers. b. The patient has a straight razor on the bathroom sink. c. The patient has a soft-bristle toothbrush in the bathroom. d. The patient has a bottle of acetaminophen on the counter.

d. Using a combination of pharmacological and compression interventions

The nurse caring for patients on the cardiac unit reviews the standards related to deep vein thrombosis prophylaxis. Which approach should the nurse recognize as being the most effective to prevent the development of deep vein thrombosis? a. Using bilateral thigh-high stockings throughout hospitalization b. Using low molecular weight heparin given subcutaneously daily c. Using bilateral leg compression devices while the patient is in bed d. Using a combination of pharmacological and compression interventions

a. Dizziness b. Extreme diaphoresis d. Heart rate 140 beats per minute e. 35 mm Hg increase in systolic blood pressure

The nurse determines that a patient recovering from an acute MI is experiencing activity intolerance. What findings did the nurse use to come to this conclusion? (Select all that apply.) a. Dizziness b. Extreme diaphoresis c. Nausea and vomiting d. Heart rate 140 beats per minute e. 35 mm Hg increase in systolic blood pressure

a. Less shivering b. Clear lung sounds c. Pulse oximeter reading 96% d. Urine output greater than 30 mL/hour f. Temperature 98.6F (37C), respirations 16/min, blood pressure 110/75 mm Hg, pulse 75 beats/min)

The nurse has been caring for a patient experiencing a reduction in cardiac output. Which findings indicate that interventions are effective, and the patient is improving? (Select all that apply.) a. Less shivering b. Clear lung sounds c. Pulse oximeter reading 96% d. Urine output greater than 30 mL/hour e. Cool pale extremities with diminished peripheral pulses f. Temperature 98.6F (37C), respirations 16/min, blood pressure 110/75 mm Hg, pulse 75 beats/min)

b. Denial of symptoms

The nurse has reinforced teaching about symptoms of an MI and the importance of seeking medical treatment promptly to a patient who has angina. What should the nurse explain as a common reason prompt treatment is not sought? a. Lack of insurance b. Denial of symptoms c. Lack of transportation d. Not aware of symptoms

a. Provide oxygen as prescribed. c. Elevate the head of the bed 45 degrees. d. Encourage frequent periods of bedrest. e. Assess vital signs and oxygen saturation.

The nurse identifies the diagnosis of decreased cardiac output for a patient with a cardiac valve disorder. Which interventions should the nurse include in this patients plan of care? (Select all that apply.) a. Provide oxygen as prescribed. b. Maintain fluid restriction of 1000 mL. c. Elevate the head of the bed 45 degrees. d. Encourage frequent periods of bedrest. e. Assess vital signs and oxygen saturation.

b. Maintain fluid restriction of 1000 mL. c. Elevate the head of the bed 45 degrees. e. Assess vital signs and oxygen saturation.

The nurse identifies the diagnosis of decreased cardiac output for a patient with a cardiac valve disorder. Which interventions should the nurse include in this patients plan of care? (Select all that apply.) a. Provide oxygen as prescribed. b. Maintain fluid restriction of 1000 mL. c. Elevate the head of the bed 45 degrees. d. Encourage frequent periods of bedrest. e. Assess vital signs and oxygen saturation.

a. Relieve pain.

The nurse is assisting with admission of a patient experiencing symptoms of an acute MI. Which activity would be the highest priority for this patient? a. Relieve pain. b. Note emotions. c. Limit fluid intake. d. Support the family.

a. Cardiac arrest

The nurse is assisting with the care of a patient who is receiving an intravenous infusion with potassium. The nurse realizes that fluids containing potassium are administered slowly and cautiously to prevent which health problem? a. Cardiac arrest b. Fluid overload c. Allergic reaction d. Metabolic acidosis

d. Clear liquid diet

The nurse is assisting with the care of a patient with an MI. Which specialized diet should the nurse expect to be prescribed for this patient? a. Soft diet b. Full liquid c. Edentulous diet d. Clear liquid diet

d. Semi-Fowlers position

The nurse is caring for a patient recovering from an MI. In which position should the nurse place the patient to decrease preload and the hearts workload? a. Prone b. Supine c. Sims position d. Semi-Fowlers position

a. Troponin I and myoglobin

The nurse is caring for a patient suspected of having an MI. What laboratory tests should the nurse review to determine if this patient did experience an MI? a. Troponin I and myoglobin b. Bleeding time and total cholesterol c. Urinalysis and complete blood count d. Alkaline phosphatase and prothrombin time

d. Measure bilateral calf circumference daily.

The nurse is caring for a patient who develops a fever and reports right calf pain with a reddened and swollen calf. Which action should the nurse take? a. Massage the affected calf. b. Place ice on the affected calf. c. Place elastic stocking on right leg. d. Measure bilateral calf circumference daily.

d. Cardiac catheterization

The nurse is caring for a patient who has a valvular problem. The patient states the doctor is ordering something that measures the pressures in the patients heart. Which diagnostic test should the nurse anticipate scheduling for the patient? a. Echocardiogram b. Chest radiograph c. Electrocardiogram d. Cardiac catheterization

a. Angina

The nurse is caring for a patient who has aortic stenosis. During data collection, which of these manifestations should indicate to the nurse that the patient is experiencing myocardial oxygen deficiency? a. Angina b. Sacral edema c. Jugular vein distention d. Pericardial friction rub

c. Atenolol (Tenormin)

The nurse is caring for a patient who has long-standing asthma and stable angina. Which medication can the nurse safely provide to the patient? a. Pindolol (Visken) b. Nadolol (Corgard) c. Atenolol (Tenormin) d. Propranolol (Inderal)

d. Calcium channel blocker

The nurse is caring for a patient who is being prepared for coronary atherectomy. Which order should the nurse expect to administer? a. Diuretic b. Beta blocker c. An antiplatelet d. Calcium channel blocker

a. Monitor for constipation. c. Monitor liver and renal functions during therapy. d. Notify physician if heart rate is less than 50 beats per minute. e. Obtain apical pulse and blood pressure before giving medication. f. Notify physician if blood pressure is less than 90 mm Hg systolic.

The nurse is caring for a patient with a cardiac history. Which actions should the nurse take when administering diltiazem (Cardizem)? (Select all that apply.) a. Monitor for constipation. b. Monitor for development of a round face. c. Monitor liver and renal functions during therapy. d. Notify physician if heart rate is less than 50 beats per minute. e. Obtain apical pulse and blood pressure before giving medication. f. Notify physician if blood pressure is less than 90 mm Hg systolic.

b. PTT

The nurse is caring for a patient with a deep vein thrombosis who is receiving intravenous heparin. The nurse should monitor which of these laboratory tests specifically for the effects of the heparin? a. PT b. PTT c. Platelets d. Bleeding time

c. An outpouching in the wall of an artery.

The nurse is caring for a patient with an abdominal aortic aneurysm. Which statement indicates that the patient understands this condition? a. A blood clot in a vein. b. An incompetent valve in a large vein. c. An outpouching in the wall of an artery. d. A deposit of plaque in the wall of an artery.

c. Anti-inflammatory

The nurse is caring for a patient with pericarditis. Which type of medication should the nurse expect to be prescribed for the patient? a. Beta blocker b. Antihypertensive c. Anti-inflammatory d. Calcium channel blocker

b. Pericardial friction rub

The nurse is collecting data from a patient 3 days after a motor vehicle crash in which the patient hit the steering wheel. The data reveal symptoms of pericarditis. Which finding indicates the presence of pericarditis? a. Pain on expiration b. Pericardial friction rub c. Jugular vein distention d. Crackles in lung bases

d. Profuse diaphoresis

The nurse is collecting data from a patient experiencing an MI. Which finding should the nurse expect? a. Flushed face b. Extreme thirst c. A moist cough d. Profuse diaphoresis

a. Leathery, brown skin

The nurse is collecting data from a patient who has chronic venous insufficiency of the lower extremities. Which finding should the nurse expect? a. Leathery, brown skin b. Diminished pedal pulse c. Absence of pedal pulses d. Pallor in the extremities

c. Rheumatic fever

The nurse is collecting data from a patient who has mitral stenosis. For which condition should the nurse assess in the patients history? a. Meningitis b. Scarlet fever c. Rheumatic fever d. Rheumatoid arthritis

d. Dorsiflexing the patients foot sharply and asking if calf pain occurs

The nurse is collecting data from a patient. Which approach should the nurse use to determine the presence of a Homans sign? a. Observing the calf and thigh color bilaterally b. Listening with a Doppler to posterior bilateral tibial pulses c. Measuring the patients calf and thigh circumference bilaterally d. Dorsiflexing the patients foot sharply and asking if calf pain occurs

a. Maintain bedrest.

The nurse is collecting data on a patient recovering from a hysterectomy who is experiencing left calf tenderness. Data include the following: left calf 17.5 inches; right calf 14 inches; left thigh 32 inches; right thigh 28 inches; shiny, warm, and reddened left leg. Which actions should the nurse recommend for this patients plan of care? a. Maintain bedrest. b. Encourage ambulation daily. c. Place anti-embolism stocking on left leg. d. Place anti-embolism stocking on both legs.

b. Back pain

The nurse is collecting data on a patient with an aortic aneurysm. Which manifestation should the nurse expect to find? a. Paralysis b. Back pain c. Chest pain d. Ankle edema

c. Aching of legs

The nurse is collecting data on a patient with varicose veins. What should the nurse document as a subjective finding of varicosities? a. Ankle edema b. Purple lesions c. Aching of legs d. Palpable nodules

d. 221 mg/dL

The nurse is concerned that a patient is at risk for MI because of the latest total cholesterol level. Which level did the nurse use to cause this concern? a. 120 mg/dL b. 138 mg/dL c. 174 mg/dL d. 221 mg/dL

b. Risk for Injury

The nurse is contributing to a patients plan of care for a patient who has an elevated INR. Which nursing diagnosis should the nurse recommend receive priority in the patients care plan? a. Acute Pain b. Risk for Injury c. Risk for Infection d. Ineffective Breathing Pattern

b. Bumetanide (Bumex)

The nurse is contributing to a patients plan of care. During medication administration, which medication would the nurse understand as being prescribed to treat a patient with aortic stenosis who has symptoms of heart failure? a. Heparin b. Bumetanide (Bumex) c. Digitalis d. Warfarin (Coumadin)

b. Elevate left leg above heart level.

The nurse is contributing to a patients plan of care. Which positioning should the nurse recommend for a patient with a left deep vein thrombosis? a. Elevate head above level of legs. b. Elevate left leg above heart level. c. Elevate right leg above heart level. d. Elevate both legs above heart level.

d. Verbalizes definition of disorder and manifestations

The nurse is contributing to a patients plan of care. Which statement is a desired outcome for the nursing diagnosis of Deficient Knowledge related to a new medical diagnosis of mitral valve prolapse? a. Exhibits less fatigue during self-care b. Clear breathing sounds, no edema or weight gain c. States ability to comply with therapeutic regimen d. Verbalizes definition of disorder and manifestations

b. Place tablet under the tongue. c. Rise slowly after taking tablet. d. Sit or lie down when taking tablet. e. Take before activity known to cause angina.

The nurse is contributing to a patients teaching plan. What should be included when teaching a patient about the use of nitroglycerin? (Select all that apply.) a. Take tablet every morning. b. Place tablet under the tongue. c. Rise slowly after taking tablet. d. Sit or lie down when taking tablet. e. Take before activity known to cause angina. f. Have a years supply of the medication at home.

b. Clear breathing sounds, no edema or weight gain

The nurse is contributing to the care plan for a patient with aortic stenosis. Which outcome supports a favorable response for the nursing diagnosis of activity intolerance? a. Verbalizes knowledge of disorder b. Clear breathing sounds, no edema or weight gain c. Vital signs within normal limits during self-care d. States willingness to comply with therapeutic regimen

c. Provide rest in bed or chair. e. Provide bedpan for elimination.

The nurse is contributing to the plan of care for a patient experiencing chest pain for 7 hours. The laboratory tests reveal elevated troponin I and myoglobin levels. What action should the nurse take when caring for this patient? (Select all that apply.) a. Elevate head of bed. b. Encourage ambulation c. Provide rest in bed or chair. d. Offer regular diet with hot tea. e. Provide bedpan for elimination.

c. Elevate legs.

The nurse is contributing to the plan of care for a patient with varicose veins. Which position should be encouraged to reduce the patients pain? a. Lie prone. b. Cross legs. c. Elevate legs. d. Keep legs dependent.

c. Take 1 tablet every 5 minutes for three doses until pain is relieved.

The nurse is contributing to the teaching plan for a patient who is taking nitroglycerin. Which action should be included if chest pain occurs? a. Take 2 tablets every 3 hours for four doses until pain is relieved. b. Take 3 tablets every 3 minutes for four doses until pain is relieved. c. Take 1 tablet every 5 minutes for three doses until pain is relieved. d. Take 2 tablets every 2 minutes for three doses until pain is relieved.

b. Take aspirin 30 minutes before niacin to reduce flushing.

The nurse is contributing to the teaching plan of a patient who is prescribed niacin. What specific recommendation should be included in the teaching plan? a. Take with meals or milk to avoid gastrointestinal upset. b. Take aspirin 30 minutes before niacin to reduce flushing. c. Increase intake of fruits and vegetables to reduce constipation. d. Take 30 minutes before morning and evening meals to avoid gastrointestinal upset.

b. Engaged in desired daily and social activities

The nurse is evaluating care provided to a patient with the nursing diagnosis of activity intolerance because of aortic regurgitation. Which outcome indicates that care has been effective? a. Stated maintained bedrest to reduce fatigue b. Engaged in desired daily and social activities c. Completed activities of daily living with assistance d. Reported no longer participates in gardening hobby

d. Smoking and high fat intake

The nurse is helping prepare a teaching plan to modify risk factors for a patient with coronary artery disease. Which risk factor should the nurse include in this patients teaching plan? a. Age and gender b. Gender and ethnicity c. Heredity and ethnicity d. Smoking and high fat intake

b. Heart failure

The nurse is monitoring a patient with aortic stenosis and notes crackles in the lungs and a cough. Which complication should the nurse suspect is occurring in this patient? a. Pneumonia b. Heart failure c. Hypertension d. Rheumatic fever

b. Pericardial sac fluid increases.

The nurse is monitoring a patient with pericarditis. What health problem is this patient at risk for developing? a. Emboli begin to form. b. Pericardial sac fluid increases. c. Cardiac workload increases by 15%. d. Cardiac output decreases more than 10%.

b. Hypertension c. Diabetes mellitus e. Increased serum iron levels f. Increased homocysteine levels

The nurse is participating in the preparation of a seminar on coronary heart disease for a group of community members. What should modifiable risk factors for atherosclerosis should the nurse include in this presentation? (Select all that apply.) a. Ethnic group b. Hypertension c. Diabetes mellitus d. Familial hyperlipidemia e. Increased serum iron levels f. Increased homocysteine levels

d. INR

The nurse is preparing to administer warfarin (Coumadin) to a patient. Which laboratory value should the nurse review before administering this medication? a. Bleeding time b. Fibrinogen level c. Partial thromboplastin time d. INR

b. Wear gloves when applying the patch. d. Remove the previous patch before applying a new one.

The nurse is preparing to apply a nitroglycerin patch to a patient with stable angina. What actions should the nurse take when providing this medication? (Select all that apply.) a. Apply the new patch before breakfast. b. Wear gloves when applying the patch. c. Encourage rest for 1 hour after applying the new patch. d. Remove the previous patch before applying a new one. e. Apply the new patch 30 minutes before removing the old one.

a. I should elevate my legs on pillows.

The nurse is providing discharge instructions to a patient with brown, leathery, edematous ankles and increased pain when sitting. Which patient statement indicates that teaching has been effective? a. I should elevate my legs on pillows. b. I should keep my legs lower than my heart. c. Elastic bandages should be wrapped from the knee down. d. I should increase my intake of red meat and dairy products.

d. Because of your heart condition, the blood flow through your heart is slower and blood may tend to pool in certain areas, which might allow tiny clots to form.

The nurse is providing discharge teaching for a patient with mitral stenosis. What should the nurse include in this teaching? a. The medications you will be taking make your blood thicker, so you are at risk for small clots to form. b. It is important that you increase your fluid intake and take iron supplements so that your body can make enough blood for your heart to pump around. c. Your blood is rushing through your heart so fast that it may not give your heart enough oxygen and you may have something called angina, or heart pain. d. Because of your heart condition, the blood flow through your heart is slower and blood may tend to pool in certain areas, which might allow tiny clots to form.

d. You may have a possible need for prophylactic anticoagulants.

The nurse is reinforcing discharge instructions to a patient who has a mitral valve prolapse. What information should be included? a. Begin a home aerobic exercise program. b. Perform hourly leg exercises if lying down. c. Deep breathe and cough hourly when awake. d. You may have a possible need for prophylactic anticoagulants.

b. Wear support stockings.

The nurse is reinforcing instructions provided to a patient to prevent the development of varicose veins. Which patient statement indicates that teaching has been effective? a. Sit with legs crossed. b. Wear support stockings. c. Stand for long periods of time. d. Sleep with the head of the bed elevated.

a. Wear Medic-Alert identification.

The nurse is reinforcing teaching for a patient who has had a mechanical valve replacement. What should be included regarding safety during warfarin (Coumadin) therapy? a. Wear Medic-Alert identification. b. Use a straight razor when shaving. c. Keep yearly blood test appointments. d. Increase intake of green leafy vegetables.

c. I will sit with my legs down.

The nurse is reinforcing teaching for managing the pain of peripheral arterial disease. Which patient statement indicates correct understanding of discharge instructions? a. I will lie down frequently. b. I will use a reclining chair. c. I will sit with my legs down. d. I will do knee flexion exercises.

d. Perform daily exercise, eat a low-fat diet, and take gemfibrozil (Lopid).

The nurse is reinforcing teaching provided to a patient to decrease the risk of atherosclerosis. Which patient statement indicates that teaching on how to reduce triglycerides with lifestyle changes and prescribed medication was effective? a. Eat a low-protein diet, limit activity, and take niacin. b. Limit activity, eat a high-protein diet, and take aspirin. c. Eat a high-fat diet, avoid smoking, and take daily furosemide (Lasix). d. Perform daily exercise, eat a low-fat diet, and take gemfibrozil (Lopid).

d. Angiotensin-converting enzyme inhibitor

The nurse is reinforcing teaching provided to a patient who has been prescribed a new medication. For which medication should the patient be instructed there is the possibility of developing a cough when taking the drug? a. Statin b. Beta blocker c. Calcium channel blocker d. Angiotensin-converting enzyme inhibitor

b. Smoking

The nurse is reinforcing teaching provided to a patient with Buergers disease on the most important modifiable risk factor. Which risk factor should the patient state that indicates teaching has been effective? a. Diet b. Smoking c. Sedentary lifestyle d. Exposure to cold temperature

c. Avoid stimulation that causes vasoconstriction.

The nurse is reinforcing teaching provided to a patient with Raynauds disease. Which measure should the nurse include to prevent an attack? a. Get plenty of outdoor exercise all year. b. Keep affected body areas covered at all times. c. Avoid stimulation that causes vasoconstriction. d. Take vasopressors to prevent exacerbation of symptoms.

c. A separation of the inner layer of the arterial wall.

The nurse is reinforcing teaching provided to a patient with an aneurysm. Which patient statement indicates correct understanding of a dissecting aneurysm? a. An outpouching of one side of the arterial wall. b. A communication between an artery and a vein. c. A separation of the inner layer of the arterial wall. d. An enlargement of the entire circumference of the artery.

d. Alternate activity with rest.

The nurse is reinforcing teaching provided to a patient with aortic regurgitation on how to reduce cardiac workload. Which patient statement indicates that teaching has been effective? a. Lie flat when in bed. b. Elevate the legs hourly. c. Eat three large meals daily. d. Alternate activity with rest.

a. There is impaired emptying of the left ventricle.

The nurse is reinforcing teaching provided to a patient with aortic stenosis. Which statement indicates that the patient correctly understands what happens in aortic stenosis? a. There is impaired emptying of the left ventricle. b. There is impaired emptying of the right ventricle. c. There is backflow of blood into the left ventricle. d. There is backflow of blood into the right ventricle.

b. Stress

The nurse is reinforcing teaching provided to a patient with coronary artery disease. Which risk factor for an MI should be included in this patients teaching plan? a. Age b. Stress c. Gender d. Ethnicity

b. Rheumatic fever.

The nurse is reinforcing teaching provided to a patient with strep throat. Which statement indicates that the patient understands the complication that can occur 2 to 3 weeks after this health problem? a. Pericarditis. b. Rheumatic fever. c. Cardiomyopathy. d. Rheumatic heart disease.

c. Duplex venous scanning

The nurse is reinforcing teaching provided to a patient with thrombophlebitis. Which diagnostic test should the nurse explain is used to confirm thrombophlebitis? a. Chest radiograph b. Intravenous pyelogram c. Duplex venous scanning d. Arterial Doppler ultrasonography

a. Prepare for ambulation.

The nurse is reinforcing the importance of leg exercises with a patient who is prescribed bedrest. Which patient statement indicates that teaching has been effective? a. Prepare for ambulation. b. Promote urinary and intestinal elimination. c. Prevent thrombophlebitis and blood clot formation. d. Decrease the likelihood of pressure ulcer formation.

b. A 68-year-old female on digoxin (Lanoxin)

The nurse is reviewing care for a group of patients. Which patient with a heart valve disorder should the nurse identify as being susceptible to developing the complication of fluid volume excess? a. A 27-year-old male on atenolol (Tenormin) b. A 68-year-old female on digoxin (Lanoxin) c. A 44-year-old male taking amoxicillin (Amoxil) d. An 18-year-old female taking warfarin (Coumadin)

c. A 76-year-old with a history of cardiac valve repair scheduled for a colonoscopy d. A 71-year-old with a history of infective endocarditis scheduled for a tooth extraction e. A 69-year-old with a history of congenital heart disease who is having an abscess drained

The nurse is reviewing the medical histories for a group of patients. Which patients should receive prophylactic antibiotics to prevent infective endocarditis (IE)? (Select all that apply.) a. A 68-year-old with a history of atrial fibrillation scheduled for a root canal b. A 55-year-old with a history of angina scheduled for arthroscopic knee surgery c. A 76-year-old with a history of cardiac valve repair scheduled for a colonoscopy d. A 71-year-old with a history of infective endocarditis scheduled for a tooth extraction e. A 69-year-old with a history of congenital heart disease who is having an abscess drained f. A 56-year-old with a history of mitral valve prolapse scheduled for routine dental cleaning

b. 17 seconds

The nurse is reviewing the prothrombin time (PT) value for a patient prescribed warfarin (Coumadin). The laboratorys prothrombin time range is 9 to 11 seconds. What would be the therapeutic time for the patient? a. 12.5 seconds b. 17 seconds c. 26 seconds d. 30 seconds

a. Unstable angina can lead to MI c. Pain with stable angina is predictable. e. Angina is caused by a lack of oxygen to the heart.

The nurse is teaching a group of patients about stable vs unstable angina. Which should the nurse include in the teaching? (Select all that apply.) a. Unstable angina can lead to MI b. Stable angina occurs at rest . c. Pain with stable angina is predictable. d. Unstable angina is relieved by medication. e. Angina is caused by a lack of oxygen to the heart.

b. You will see a lot of equipment in the room

The nurse is teaching a patient about an upcoming cardiac catheterization and coronary arteriogram. What information should the nurse include in this teaching? a. You will be able to hear your heart beating. b. You will see a lot of equipment in the room. c. You will feel a heavy sensation throughout your body. d. You will not feel anything because you will be anesthetized.

b. I will call an ambulance and report your chest pain.

The nurse receives a telephone call from a relative who was diagnosed with angina last year. The relative reports taking 5 nitroglycerin (NTG) tablets but still has chest pain. What would be the best advice for the nurse to give this relative? a. Take two more NTG tablets and lie down. b. I will call an ambulance and report your chest pain. c. Drive yourself to the emergency department immediately. d. Have someone drive you to the emergency department now.

b. "I will have monthly blood tests done."

The nurse reinforces teaching provided to a patient prescribed an anticoagulant for atrial fibrillation due to valvular disease. Which statement by the patient indicates that the teaching has been effective? a. "I can take aspirin for my frequent headaches." b. "I will have monthly blood tests done." c. "I feel fine, so I do not need to wear a Medic-Alert bracelet anymore." d. "I care for my teeth very well, brushing them with a hard brush and flossing daily."

a. I will have monthly blood tests done.

The nurse reinforces teaching provided to a patient prescribed an anticoagulant for atrial fibrillation due to valvular disease. Which statement by the patient indicates that the teaching has been effective? a. I will have monthly blood tests done. b. I can take aspirin for my frequent headaches. c. I feel fine, so I do not need to wear a Medic-Alert bracelet anymore. d. I care for my teeth very well, brushing them with a hard brush and flossing daily.

d. The top chamber on the left side of the heart doesnt empty all of the way.

The nurse reinforces teaching provided to a patient with mitral stenosis. Which patient statement indicates that the teaching has been effective? a. The right side of the heart is not pumping effectively. b. There is a backflow of blood into the lower left chamber of the heart. c. There is a narrowing of the blood vessel that brings blood into the heart. d. The top chamber on the left side of the heart doesnt empty all of the way.

c. Less heart muscle is damaged.

The nurse reviews the importance of seeking medical treatment with a patient at risk for an MI. Which patient statement indicates that teaching has been effective? a. Angina is prevented. b. Risk factors are decreased. c. Less heart muscle is damaged. d. Coronary artery disease is cured.

a. Cloudy urine b. Lung crackles d. Elevated temperature e. Yellow-green sputum

The nurse suspects that a patient recovering from valve replacement surgery is experiencing an infection. Which findings did the nurse use to come to this conclusion? (Select all that apply.) a. Cloudy urine b. Lung crackles c. Incisional pain d. Elevated temperature e. Yellow-green sputum

b. Report the vital signs to the RN.

The physician prescribes nitroglycerin for a patient with anterior MI. The patients vital signs are apical pulse 52 beats/min and blood pressure 80/60 mm Hg. What action should the nurse take? a. Administer the drug as ordered. b. Report the vital signs to the RN. c. Recheck vital signs in 30 minutes. d. Give medication at half the prescribed dose.

a. Decreases anxiety b. Opens bronchioles c. Relieves chest pain d. Decreases preload and afterload

The spouse of a patient experiencing an acute MI does not understand why the patient is receiving morphine sulfate for pain. What should the nurse explain to the patient and spouse? (Select all that apply.) a. Decreases anxiety b. Opens bronchioles c. Relieves chest pain d. Decreases preload and afterload e. Reduces myocardial oxygen needs

c. Intermittent claudication

Which of these conditions manifests itself as a cramping pain in the legs during or after walking. a. None of these b. Peripheral Vascular Disease c. Intermittent claudication d. Angina

a. Cardiac workload is increased from reduced cardiac output.

While collecting data on a patient with aortic stenosis the nurse monitors for signs of heart failure. What is the nurse monitoring for heart failure as a complication of aortic stenosis? a. Cardiac workload is increased from reduced cardiac output. b. Cardiac workload is decreased from reduced cardiac output. c. Cardiac workload is increased from increased cardiac output. d. Cardiac workload is decreased from increased cardiac output.