NURS 220 Final (3/3)

While caring for a patient with aortic stenosis, the nurse establishes a nursing diagnosis of acute pain related to decreased coronary blood flow. An appropriate intervention by the nurse is to A. promote rest to decrease myocardial oxygen demand. B. educate the patient about the need for anticoagulant therapy. C. teach the patient to use sublingual nitroglycerin for chest pain. D. elevate the head of the bed 60 degrees to decrease venous return.

A. promote rest to decrease myocardial oxygen demand.

A patient with no history of heart disease has a rhythm strip that shows an occasional distorted P wave followed by normal AV and ventricular conduction. The nurse questions the patient about A. the use of caffeine B. the use of sedatives C. any aerobic training. D. holding of breath during exertion

A. the use of caffeine

A. Who has a higher incidence of HF, develop it at an earlier age, and a higher mortality rate? B. Who has an extremely high risk for ACE inhibitor-related cough? C. Who experiences more ACE inhibitor related angioedema than whites?

A. African Americans B. Asians C. African Americans

When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial BP of 140/80 and an ankle pressure of 110/70. The nurse calculates the patient's ankle-brachial index (ABI) as

0.79

When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular cardiac rhythm, the nurse finds there are 25 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as

60 There are 1500 small blocks in a minute, and the nurse will divide 1500 by 25.

The nurse obtains a blood pressure of 180/75 mm Hg for a patient. What is the patient's mean arterial pressure (MAP)?

110

When a patient requires defibrillation, in which order will the nurse accomplish the following steps? a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the paddles on the patient's chest. e. Check the location of other personnel and call out "all clear."

A, C, D, E, B

A. Who has a lower death rates from heart disease than whites B. Who has heart disease mortality rates twice as high as other Americans C. Who has the highest incidence of coronary artery disease D. Who has an early age of onset of CAD

A. Hispanics B. Native Americans C. White, middle-aged men D. African Americans

For a patient who has been admitted the previous day to the coronary care unit with an acute myocardial infarction (AMI), the nurse will anticipate teaching about A. typical emotional responses to AMI. B. when patient cardiac rehabilitation will begin. C. discharge drugs such as aspirin and b-blockers. D. the pathophysiology of coronary artery disease.

B. when patient cardiac rehabilitation will begin. Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will prevent good understanding of complex information such as coronary artery disease (CAD) pathophysiology. Teaching about discharge medications should be done when the time for discharge is closer. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional response to myocardial infarction (MI).

While obtaining an admission health history from a patient with possible rheumatic fever, which question will be most pertinent to ask? A. "Have you had a recent sore throat?" B. "Are you using any illegal IV drugs?" C. "Do you have any family history of congenital heart disease?" D. "Can you recall having any chest injuries in the last few weeks?"

A. "Have you had a recent sore throat?" Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit intravenous (IV) drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.

The nurse performs discharge teaching for a patient with an implantable cardioverter-defibrillator. Which statement by the patient indicates to the nurse that further teaching is needed? A. "I can expect redness and swelling of the incision site for a few days." B. "I should not stand next to antitheft devices at the exit of stores." C. "My family needs to keep up to date on how to perform CPR." D. "The device may set off the metal detectors in an airport."

A. "I can expect redness and swelling of the incision site for a few days." Patients should be taught to report any signs of infection at incision site (e.g., redness, swelling, drainage) or fever to their primary care provider immediately.

When evaluating the outcomes of preoperative teaching with a patient scheduled for a coronary artery bypass graft (CABG) using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says, A. "I will have incisions in my leg where they will remove the vein." B. "They will circulate my blood with a machine during the surgery." C. "I will need to take an aspirin a day after the surgery to keep the graft open." D. "They will use an artery near my heart to bypass the area that is obstructed."

A. "I will have incisions in my leg where they will remove the vein." When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.

The nurse performs discharge teaching for a patient diagnosed with infective endocarditis. Which statement by the patient indicates to the nurse that teaching was successful? A. "I will inform my dentist about my hospitalization for infective endocarditis." B. "I will need antibiotics before having any invasive procedure or surgery." C. "An elevated temperature is expected and can be managed by taking acetaminophen." D. "I should not be alarmed if I have difficulty breathing or pink-tinged sputum."

A. "I will inform my dentist about my hospitalization for infective endocarditis." Patients with infective endocarditis should inform their dental providers of their health history. Antibiotic prophylaxis is recommended for patients with a history of infective endocarditis who have certain dental procedures performed. Antibiotics are not indicated before genitourinary or gastrointestinal procedures unless an infection is present. Patients should immediately report the presence of fever or clinical manifestations indicating heart failure to their health care provider.

After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? A. "It is important not to suddenly stop taking the atenolol." B. "Atenolol will increase the strength of my heart muscle." C. "I can expect to feel short of breath when taking atenolol." D. "Atenolol will improve the blood flow to my coronary arteries."

A. "It is important not to suddenly stop taking the atenolol." Patients who have been taking b-blockers can develop intense and frequent angina if the medication is suddenly discontinued. Atenolol (Tenormin) decreases myocardial contractility. Shortness of breath that occurs when taking b-blockers for angina may be due to bronchospasm and should be reported to the health care provider. Atenolol works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries.

The nurse admits a patient with a dysrhythmia. The nurse is aware that careful monitoring for asystole is necessary if the patient receives which medication? A. Digoxin (Lanoxin) B. Metoprolol (Lopressor) C. Atropine D. Adenosine (Adenocard)

A. Adenosine (Adenocard) IV adenosine (Adenocard) is the first drug of choice to convert supraventricular tachycardia to a normal sinus rhythm. Adenosine is administered IV rapidly (over 1 or 2 seconds) followed by a rapid, normal saline flush. The nurse should monitor the patient's ECG continuously because a brief period of asystole is common.

A. Who does not produce as much renin and does not respond as well to angiotensin inhibitors? B. Who is less likely to receive treatment for hypertension? C. Who has the highest prevalence of HTN in the world?

A. African Americans B. Mexican Americans C. African Americans

A patient develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated? A. Assist the patient to a sitting position at the bedside B. Instruct the patient to use pursed-lip breathing C. Restrict oral fluid intake to 500 mL per day D. Perform a bladder scan to assess for urinary retention

A. Assist the patient to a sitting position at the bedside The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation.

A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger's disease). When the nurse is planning expected outcomes for the patient, which outcome has the highest priority for this patient? A. Cessation of smoking B. Control of serum lipid levels C. Maintenance of appropriate weight D. Demonstration of meticulous foot care

A. Cessation of smoking Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease.

A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports all the following symptoms to the nurse. Which is most important to communicate to the health care provider? A. Generalized muscle aches and pains B. Skin flushing after taking the medications C. Dizziness when changing positions quickly D. Nausea when taking the drugs before eating

A. Generalized muscle aches and pains Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute renal failure and death in some patients who have taken the statin medications. These symptoms indicate that the rosuvastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow up with the patient, they do not indicate that a change in medication is needed.

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? A. Have the patient record dietary intake for 3 days. B. Give the patient a detailed list of low-sodium foods C. Teach the patient about foods that are high in sodium. D. Help the patient make an appointment with a dietitian.

A. Have the patient record dietary intake for 3 days. The initial nursing action should be assessment of the patient's baseline dietary intake through a 3-day food diary. The other actions may be appropriate, but assessment of the patient's baseline should occur first.

While caring for a patient with aortic stenosis, the nurse establishes a nursing diagnosis of acute pain related to decreased coronary blood flow. An appropriate intervention by the nurse is to A. promote rest to decrease myocardial oxygen demand. B. educate the patient about the need for anticoagulant therapy. C. teach the patient to use sublingual nitroglycerin for chest pain. D. elevate the head of the bed 60 degrees to decrease venous return.

A. promote rest to decrease myocardial oxygen demand. Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation.

A patient is admitted to the emergency department with a blood pressure of 234/148 mm Hg and started on intravenous nitroprusside (Nitropress). What should the nurse determine as an appropriate goal for the first hour of treatment? A. Mean arterial pressure no less than 133 mm Hg B. Mean arterial pressure between 70 and 110 mm Hg C. Mean arterial pressure no greater than 120 mm Hg D. Mean arterial pressure less than 70 mm Hg

A. Mean arterial pressure no less than 133 mm Hg The initial treatment goal is to decrease mean arterial pressure by no more than 25% within minutes to 1 hour. If the patient is stable, the goal for BP is 160/100 to 110 mm Hg over the next 2 to 6 hours. Lowering the blood pressure too much may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. Additional gradual reductions toward a normal blood pressure should be implemented over the next 24 to 48 hours if the patient is clinically stable.

Which action will the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? A. Monitor blood pressure frequently. B. Encourage patient to ambulate in room C.Titrate nesiritide rate slowly before discontinuing. D. Teach patient about safe home use of the medication.

A. Monitor blood pressure frequently. Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Since the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration and is used for ADHF but not in a home setting.

A patient with a history of an abdominal aortic aneurysm is admitted to the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first? A. Obtain the blood pressure. B. Ask the patient about tobacco use. C. Draw blood for ordered laboratory testing. D. Assess for the presence of an abdominal bruit.

A. Obtain the blood pressure. Since the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.

To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the length of the patient's A. P wave. B. PR interval. C. QT interval. D. QRS complex.

A. P wave. The P wave represents the depolarization of the atria. The P-R interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibers. The QRS represents ventricular depolarization. The Q-T interval represents depolari

The nurse is reviewing the laboratory tests for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? A. Serum creatinine of 2.6 mg/dL B. Serum potassium of 3.8 mEq/L C. Serum hemoglobin of 14.7 g/dL D. Blood glucose level of 98 mg/dL

A. Serum creatinine of 2.6 mg/dL The elevated creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.

The nurse prepares to administer digoxin (Lanoxin) 0.125 mg to a patient. What should the nurse assess before giving the medication? A. Serum potassium level B. Prothrombin time C. Hemoglobin and hematocrit D. Urine specific gravity

A. Serum potassium level Serum potassium should be monitored because hypokalemia increases the risk for digoxin toxicity.

The nurse is teaching a patient about risk factors for aortic abdominal aneurysms. Which risk factors should the nurse include in the teaching plan? A. Smoking, high cholesterol, and hypertension B. Female gender, hyperhomocysteinemia, and substance abuse C. Diabetes mellitus, obesity, and metabolic syndrome D. Physical inactivity, African American, and renal insufficiency

A. Smoking, high cholesterol, and hypertension The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Risk factors include male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.

When caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty, which action should the nurse take first? A. Take the blood pressure and pulse rate. B. Check for the presence of pedal pulses. C. Assess the appearance of any ischemic ulcers. D. Start discharge teaching about antiplatelet drugs

A. Take the blood pressure and pulse rate. Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions also are appropriate but can be done after determining that bleeding is not occurring.

Which action by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs? A. The nurse assists the patient to do active range of motion exercises for all extremities. B. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID and bracelet. C. The nurse gives atenolol (Tenormin) to the patient without consulting first with the health care provider. D. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.

A. The nurse assists the patient to do active range of motion exercises for all extremities. The patient should avoid moving the arm on the ICD insertion site until healing has occurred in order to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient.

Which assessment information obtained by the nurse for a patient with aortic stenosis would be most important to report to the health care provider? A. The patient complains of chest pain associated with ambulation. B. A loud systolic murmur is audible along the right sternal border. C. A thrill is palpable at the 2nd intercostal space, right sternal border. D. The point of maximum impulse (PMI) is at the left midclavicular line.

A. The patient complains of chest pain associated with ambulation. Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.

A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. An appropriate nursing diagnosis based on these findings is A. activity intolerance related to arthralgia. B. risk for infection related to open skin lesions. C. chronic pain related to permanent joint fixation. D. risk for impaired skin integrity related to pruritus.

A. activity intolerance related to arthralgia. The patient's joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic fever are not open or pruritic. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes.

A patients rhythm strip indicates a normal heart rate and rhythm with normal P wave and QRS complex, but the PR interval is 0.26 sec. The most appropriate action by the nurse is to A. continue to assess the patient B. administer atropine per protocol C. prepare the patient for synchronized cardioversion D. prepare the patient for placement of a temporary pacemaker

A. continue to assess the patient A rhythm pattern that is normal except for a prolonged PR interval is characteristic of a first-degree heart block. First degree heart blocks are not treated but are observed for progression to higher degrees of heart block. De-fibrillation is used only for ventricular fibrillation, atropine is administered for bradycardias, and pacemakers are used for higher degree heart blocks.

When caring for the patient with infective endocarditis of the tricuspid valve, the nurse will plan to monitor the patient for A. dyspnea. B. flank pain. C. hemiparesis. D. splenomegaly.

A. dyspnea. Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, hemiparesis, and splenomegaly would be associated with embolization from the left-sided valves.

A 55-year-old with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is appropriate? A. "Since you are diabetic, you would not be a candidate for a heart transplant." B. "The choice of a patient for a heart transplant depends on many different factors." C. "Your heart failure has not reached the stage in which heart transplants are considered." D. "People who have heart transplants are at risk for multiple complications after surgery."

B. "The choice of a patient for a heart transplant depends on many different factors." Indications for a heart transplant include end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Diabetic patients who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patient's question.

A patient develops symptomatic third-degree heart block. Which instructions should the nurse provide to the patient before initiating emergency transcutaneous pacing? A. "The device uses overdrive pacing to slow the heart to a normal rate." B. "The device delivers a current through your skin that will be uncomfortable." C. "The device converts your heart rate and rhythm back to normal." D. "The device fires only if your heart rate falls below 60 beats/minute."

B. "The device delivers a current through your skin that will be uncomfortable." Before initiating transcutaneous pacing (TCP) therapy, it is important to tell the patient what to expect. The nurse should explain that the muscle contractions created by the pacemaker when the current passes through the chest wall are uncomfortable.

Which BP finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of heart failure? A. 108/64 mm Hg B. 128/76 mm Hg C. 140/90 mm Hg D. 136/ 82 mm Hg

B. 128/76 mm Hg The goal for antihypertensive therapy for a patient with hypertension and heart failure is a BP of <130/80 mm Hg. The BP of 108/64 may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

The nurse in the emergency department received change-of-shift report on four patients with hypertension. Which patient should the A. 52-year-old with a BP of 212/90 who has intermittent claudication B. 43-year-old with a BP of 190/102 who is complaining of chest pain C. 50-year-old with a BP of 210/110 who has a creatinine of 1.5 mg/dL D. 48-year-old with a BP of 200/98 whose urine shows microalbuminuria

B. 43-year-old with a BP of 190/102 who is complaining of chest pain The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention is needed. The symptoms of the other patients also show target organ damage, but are not indicative of acute processes.

A patient is admitted with venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse assess while the patient is receiving this medication? A. International normalized ratio (INR) B. Activated partial thromboplastin time (APTT) C. Anti-factor Xa D. Platelet count

B. Activated partial thromboplastin time (APTT) Unfractionated heparin can be given by continuous intravenous (IV) for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time (aPTT).

A patient has ST segment changes that indicate an acute inferior wall myocardial infarction. Which lead will be best for monitoring the patient? A. I B. II C. V6 D. MCL1

B. II Lead II reflects the inferior area of the heart that is experiencing the ST segment changes and will best reflect any electrocardiographic (ECG) changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes.

A patient with Raynaud's phenomenon is prescribed diltiazem (Cardizem). To evaluate the patient's response to this medication, what is most important for the nurse to assess in this patient? A. Increased prothrombin time (PT) B. Improved perfusion to distal fingers C. Increased mean arterial pressure D. Increased capillary refill time

B. Improved perfusion to distal fingers Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel blocker that will relax smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. There will be improved perfusion to the fingertips and a reduction of the vasospastic attacks.

A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of how many beats/minute? A. 15 to 20 B. 20 to 40 C. 40 to 60 D. 60 to 100

C. 40 to 60 If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40 to 60. The slower rates are typical of the bundle of His and the Purkinje system and may be seen with failure of both the SA and AV node to discharge. The normal SA node rate is 60 to 100 beats/minute.

When the nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important to communicate to the health care provider? A. Absence of flatus B. Loose, bloody stools C. Hypotonic bowel sounds D. Abdominal pain with palpation

B. Loose, bloody stools Loose, bloody stools at this time may indicate intestinal ischemia or infarction and should be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.

hich nursing action will be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? A. Record hourly chest tube drainage. B. Monitor fluid intake and urine output. C. Check the abdominal wound for redness or swelling. D. Teach the reason for a prolonged rehabilitation process.

B. Monitor fluid intake and urine output. Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.

Which information about a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? A. Complaint of left calf pain B. New onset shortness of breath C. Red skin color of left lower leg D. Temperature of 100.4° F (38° C)

B. New onset shortness of breath New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as oxygen administration and notification of the health care provider. The other findings are typical of VTE.

What should the nurse include in health teaching to prevent rheumatic fever? A. Antibiotic therapy before dental surgery for individuals with rheumatoid arthritis B. Prompt recognition and treatment of streptococcal pharyngitis C. Completion of 4 to 6 weeks of antibiotic therapy for infective endocarditis D. Avoidance of respiratory infections in children born with heart defects

B. Prompt recognition and treatment of streptococcal pharyngitis The nurse should educate the community to seek medical attention for symptoms of streptococcal pharyngitis and to emphasize the need for prompt and adequate treatment of this infection.

Which assessment finding in a patient who is hospitalized with infective endocarditis (IE) is most important to communicate to the health care provider? A. Generalized muscle aching B. Sudden onset left flank pain C. Janeway's lesions on the palms D. Temperature 100.5° F (38.1° C)

B. Sudden onset left flank pain Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE but do not require any new interventions.

A patient who has had a femoral-popliteal bypass graft to the right leg is being cared for on the surgical unit. Which action by an LPN/LVN caring for the patient requires the RN to intervene? A. The LPN/LVN places the patient in a Fowler's position for meals. B. The LPN/LVN has the patient sit in a bedside chair for 90 minutes. C. The LPN/LVN assists the patient to ambulate 40 feet in the hallway. D. The LPN/LVN administers the ordered aspirin 160 mg after breakfast.

B. The LPN/LVN has the patient sit in a bedside chair for 90 minutes. The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for venous thromboembolism (VTE). The other actions by the LPN/LVN are appropriate.

The nurse supervises a nursing assistant who is taking blood pressures on the unit. The nurse should intervene if which is observed? A. The nursing assistant takes a forearm blood pressure of an obese person. B. The nursing assistant deflates the cuff at a rate of 8 mm Hg per second. C. The nursing assistant waits 2 minutes after position changes to take orthostatic pressures. D. The nursing assistant takes the blood pressure with the arm at the level of the heart.

B. The nursing assistant deflates the cuff at a rate of 8 mm Hg per second. The cuff should be deflated at a rate of 2 to 3 mm Hg per second. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient. The arm should be supported at the level of the heart for accurate blood pressure measurements.

Which information obtained by the nurse when assessing a patient admitted with mitral valve regurgitation should be communicated to the health care provider immediately? A. The patient has 4+ peripheral edema in both legs. B. The patient has crackles audible to the lung apices. C. The patient has a palpable thrill felt over the left anterior chest. D. The patient has a loud systolic murmur all across the precordium.

B. The patient has crackles audible to the lung apices. Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.

After the nurse delivers 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately? A. Ask the patient to report any chest pain or discomfort. B. Turn the synchronizer switch to the "off" position. C. Administer 250 mL of 0.9% saline solution intravenously. D. Assess the apical pulse and blood pressure.

B. Turn the synchronizer switch to the "off" position. Ventricular fibrillation produces no effective cardiac contractions or cardiac output. If during synchronized cardioversion the patient becomes pulseless or the rhythm deteriorates to ventricular fibrillation, the nurse should turn the synchronizer switch off and initiate defibrillation.

A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to A. give IV diazepam (Valium) 2.5 mg. B. administer IV morphine sulfate 2 mg. C. increase nitroglycerin (Tridil) infusion by 5 mcg/min. D. increase dopamine (Intropin) infusion by 2 mcg/kg/min.

B. administer IV morphine sulfate 2 mg. Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it also will increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.

A patient has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining a nursing history from the patient, it will be most important to ask about A. back or lumbar pain. B. difficulty swallowing. C. abdominal tenderness. D. changes in bowel habits.

B. difficulty swallowing. Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms will be important to assess for in patients with abdominal aortic aneurysms.

Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should A. check the electrocardiogram (ECG) for variations in rate in relation to inspiration and expiration. B. note when Korotkoff sounds are audible during both inspiration and expiration. C. auscultate for a pericardial friction rub that increases in volume during inspiration. D. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).

B. note when Korotkoff sounds are audible during both inspiration and expiration. Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on the assessment finding of A. fever, chills, and diaphoresis. B. urine output less than 30 mL/hr. C. petechiae of the buccal mucosa and conjunctiva. D. increase in pulse rate of 15 beats/minute with activity.

B. urine output less than 30 mL/hr. Decreased renal perfusion caused by inadequate cardiac output will lead to poor urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise.

1/1 The nurse provides discharge instructions for a patient with cardiomyopathy. Which statement, if made by the patient, indicates that further teaching is necessary? A. My family will need to take a CPR course." B. "I will avoid lifting heavy objects." C. "I can drink alcohol in moderation." D. "I will reduce stress by learning guided imagery.

C. "I can drink alcohol in moderation." Patients with cardiomyopathy should avoid alcohol consumption, especially alcohol-related dilated cardiomyopathy.

The nurse provides dietary teaching for a patient with heart failure. The nurse determines that teaching is successful if the patient which statement? A. "I can add salt when preparing foods but not at the table." B. "I can have unlimited amounts of foods labeled as reduced sodium." C. "I will limit the amount of milk and cheese in my diet." D. "I will take my diuretic pill if my sodium intake is high."

C. "I will limit the amount of milk and cheese in my diet." Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet. Salt should not be added during food preparation or at the table. Foods labeled as reduced sodium contain at least 25% less sodium than regular. Diuretics should be taken as prescribed (usually daily) and not based on sodium intake.

Which of these statements made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? A. "I will switch from whole milk to 1% or nonfat milk." B. "I like fresh salmon and I will plan to eat it more often." C. "I will miss being able to eat peanut butter sandwiches." D. "I can have a cup of coffee with breakfast if I want one."

C. "I will miss being able to eat peanut butter sandwiches." Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

The nurse instructs a patient with hypertension about benazepril (Lotensin). Which statement by the patient to the nurse indicates understanding about the instructions? A. "I will need to eat foods such as bananas and potatoes that are high in potassium." B. "It is normal to have some swelling in my face while taking this medication." C. "If I develop a dry cough while taking this medication, I should notify my doctor. D. "If I take this medication, I will not need to follow a special diet."

C. "If I develop a dry cough while taking this medication, I should notify my doctor. Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema, and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced sodium diet.

To assist the patient with coronary artery disease (CAD) in making appropriate dietary changes, which of these nursing interventions will be most effective? A. Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary. B. Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes. C. Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible. D. Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet.

C. Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible. Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Removing saturated fat from the diet completely is not a realistic expectation; up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

Three days after a myocardial infarction (MI), the patient develops chest pain that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next? A. Palpate the radial pulses bilaterally. B. Assess the feet for peripheral edema. C. Auscultate for a pericardial friction rub. D. Check the cardiac monitor for dysrhythmias.

C. Auscultate for a pericardial friction rub. The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms.

An outpatient who has heart failure returns to the clinic after 2 weeks of therapy with carvedilol (Coreg). Which of these assessment findings is most important for the nurse to report to the health care provider? A. Pulse rate of 56 B. 2+ pedal edema C. BP of 88/42 mm Hg D. Complaints of fatigue

C. BP of 88/42 mm Hg The patient's BP indicates that the dose of carvedilol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of b-adrenergic blockade, but the rate of 56 is not unusual with b-blocker therapy. b-adrenergic blockade initially will worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 110. Based on this information, which nursing diagnosis is a priority for the patient? A. Acute pain related to myocardial ischemia B. Anxiety related to perceived threat of death C. Decreased cardiac output related to cardiogenic shock D. Activity intolerance related to decreased cardiac output

C. Decreased cardiac output related to cardiogenic shock All the nursing diagnoses may be appropriate for this patient, but the hypotension indicates that the priority diagnosis is decreased cardiac output, which will decrease perfusion to all vital organs (e.g., brain, kidney, heart).

A patient has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient? A. 1200-calorie-restricted diet B. High-carbohydrate diet C. High-protein diet D. Low-fat diet

C. High-protein diet A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. For patients with diabetes mellitus, maintaining normal blood glucose levels assists the healing process. For overweight individuals and no active venous ulcer, a weight-loss diet should be considered.

Which information should the nurse include when teaching a patient with newly diagnosed hypertension? A. Dietary sodium restriction will control BP for most patients. B. Most patients are able to control BP through lifestyle changes. C. Hypertension is usually asymptomatic until significant organ damage occurs. D. Annual BP checks are needed to monitor treatment effectiveness.

C. Hypertension is usually asymptomatic until significant organ damage occurs. Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes and sodium restriction are used to help manage blood pressure, but drugs are needed for most patients. BP should be checked by the health care provider every 3 to 6 months.

A patient who is complaining of a "racing" heart and nervousness comes to the emergency department. The nurse places the patient on a cardiac monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? A. Get ready to perform electrical cardioversion. B. Have the patient perform the Valsalva maneuver. C. Obtain the patient's blood pressure and oxygen saturation. D. Prepare to give b-blocker medication to slow the heart rate.

C. Obtain the patient's blood pressure and oxygen saturation. The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia; further assessment is needed before determining the treatment. Vagal stimulation or b-blockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias, but would not be used for sinus tachycardia.

The nurse is monitoring a patient's cardiac rhythm. Which rhythm would require the nurse to take immediate action? A. Sinus tachycardia with a rate of 110 beats/minute B. Atrial fibrillation with 6 to 8 QRS complexes per 6 second strip C. Premature ventricular contractions (PVCs) at a rate of 12 per minute. D. First-degree AV block with a heart rate of 56 beats/minute

C. Premature ventricular contractions (PVCs) at a rate of 12 per minute. Frequent premature ventricular contractions (PVCs) (greater than 1 every 10 beats) may reduce the cardiac output and precipitate angina and heart failure, depending on their frequency. Because PVCs in CAD or acute MI indicate ventricular irritability, the patient's physiologic response to PVCs must be monitored. Frequent PVCs will most likely need to be treated with oxygen therapy, electrolyte replacement, or antidysrhythmic agents

The home care nurse visits a patient with chronic heart failure. Which clinical manifestations,if assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)? A. Fatigue, orthopnea, and dependent edema B. Oxygen saturation at 90% and respirations 26 breaths/minute C. Severe dyspnea and blood streaked frothy sputum D. Temperature is 100.4o F and pulse is 102 beats/minute

C. Severe dyspnea and blood streaked frothy sputum Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate greater than 30 breaths per minute, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.

The nurse is taking a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC). Which information obtained by the nurse is most relevant? A. The patient reports using cocaine once at age 16 B. .The patient has a history of a recent upper respiratory infection. C. The patient's 29-year-old brother has had a sudden cardiac arrest. D. The patient has a family history of coronary artery disease (CAD).

C. The patient's 29-year-old brother has had a sudden cardiac arrest. About half of all cases of HC have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people; the information about the patient's brother will be helpful in planning care (such as an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against use of stimulant drugs, but the one-time use indicates that the patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy, but not for HC.

A patient with chronic heart failure who has prescriptions for a diuretic, an ACE-inhibitor, and a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's first action will be to A. ask the patient to recall the dietary intake for the last 3 days. B. question the patient about the use of the prescribed medications. C. assess the patient for clinical manifestations of acute heart failure. D. teach the patient about the importance of dietary sodium restrictions.

C. assess the patient for clinical manifestations of acute heart failure. The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include A. canned and frozen fruits. B. fresh or frozen vegetables. C. milk, yogurt, and other milk products. D. eggs and other high-cholesterol foods.

C. milk, yogurt, and other milk products. Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2000 mg sodium diet. The other foods listed have minimal levels of sodium and can be eaten without restriction.

A patient develops acute pericarditis after a myocardial infarction. It is most important for the nurse to assess for which clinical manifestation? A. Distant and muffled heart sounds B. Increased chest pain with deep breathing C. Presence of a pericardial friction rub D. Decreased blood pressure with tachycardia

D. Decreased blood pressure with tachycardia Cardiac tamponade is a serious complication of acute pericarditis. Signs and symptoms indicating cardiac tamponade include narrowed pulse pressure, tachypnea, tachycardia, and a decreased cardiac output (resulting in decreased blood pressure and tachycardia). The other symptoms are consistent with acute pericarditis.

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The nurse teaches a patient about lifestyle modifications to reduce high blood pressure. Which statement by the patient requires an intervention by the nurse? A. I will avoid adding salt to my food while cooking." B. "If I lose weight, I might not need to continue taking medications." C. "Diet changes can be as effective as taking blood pressure medications." D. "I can reduce my blood pressure by switching to smokeless tobacco use."

D. "I can reduce my blood pressure by switching to smokeless tobacco use." Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to =1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (such as the DASH diet) lowers blood pressure and these decreases compare with those achieved with blood pressure lowering medication.

The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge concerning long-term management of rheumatic fever when a 30-year-old recovering from rheumatic fever says, A. I will need to have monthly antibiotic injections for 10 years or longer." B. "I will need to take aspirin or ibuprofen (Motrin) to relieve my joint pain." C. "I will call the doctor if I develop excessive fatigue or difficulty breathing." D. "I will be immune to further episodes of rheumatic fever after this infection."

D. "I will be immune to further episodes of rheumatic fever after this infection." Patients with a history of rheumatic fever are more susceptible to a second episode. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance

A patient with chronic heart failure and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed. Which response by the nurse is accurate? A. "The medication reduces clotting factors by decreasing serum potassium levels." B. "The medication increases your heart rate so clots do not form in your heart." C. "The medication dissolves any clots that develop in your coronary arteries." D. "The medication prevents blood clots from forming in your heart."

D. "The medication prevents blood clots from forming in your heart." Chronic heart failure causes enlargement of the chambers of the heart and an altered electrical pathway especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and require treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin K-dependent clotting factors.

The nurse has received change-of-shift report about the following patients on the telemetry unit. Which patient should the nurse see first? A. A patient with atrial fibrillation, rate 88, who has a new order for warfarin (Coumadin) B. A patient with type 1 second-degree atrioventricular (AV) block, rate 60, who is dizzy when ambulating C. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago D. A patient whose implantable cardioverter-defibrillator (ICD) fired three times today who has a dose of amiodarone (Cordarone) due

D. A patient whose implantable cardioverter-defibrillator (ICD) fired three times today who has a dose of amiodarone (Cordarone) due The frequent firing of the ICD indicates that the patient's ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered.

When administering IV nitroglycerin (Tridil) to a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? A. Check blood pressure. B. Monitor apical pulse rate. C. Monitor for dysrhythmias. D. Ask about chest discomfort.

D. Ask about chest discomfort. The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and BP and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 38%? A. Need to participate in an aerobic exercise program several times weekly B. Use of salt substitutes to replace table salt when cooking and at the table C. Importance of making a yearly appointment with the primary care provider D. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors

D. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually.

The nurse admits a patient with hypertension. The nurse will closely monitor for hypokalemia if the patient receives which of the following medications? A. Clonidine (Catapres) B. Spironolactone (Aldactone) C. Amiloride (Midamor) D. Bumetanide (Bumex)

D. Bumetanide (Bumex) Bumetanide is a loop diuretic; hypokalemia is a common adverse effect of this medication. Amiloride is a potassium-sparing diuretic; spironolactone is an aldosterone-receptor blocker. Hyperkalemia is an adverse effect of both amiloride and spironolactone. Clonidine is a central-acting á-adrenergic antagonist and does not cause electrolyte abnormalities.

1/1 The nurse obtains the following data when caring for a patient who experienced an acute myocardial infarction (AMI) 2 days previously. Which information is most important to report to the health care provider? A. The patient denies ever having a heart attack. B. The cardiac-specific troponin level is elevated. C. The patient has occasional premature atrial contractions (PACs). D. Crackles are auscultated bilaterally in the mid-lower lobes.

D. Crackles are auscultated bilaterally in the mid-lower lobes. The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in cardiac troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.

A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when giving the medication? A. Administer the medication at the patient's bedtime. B. Have the patient take this medication with an aspirin. C. Encourage the patient to take the colesevelam with a sip of water. D. Give the patient's other medications 2 hours after the colesevelam.

D. Give the patient's other medications 2 hours after the colesevelam. The bile acid sequestrants interfere with the absorption of other drugs, and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. An increased fluid intake is encouraged for patients taking the bile acid sequestrants to reduce the risk for constipation. For maximum effect, colesevelam should be administered with meals.

A patient has peripheral artery disease. Which symptom, if experienced by the patient, indicates to the nurse that the patient is experiencing intermittent claudication? A. Patient complains of chest pain with strenuous activity B. Patient has numbness and tingling of the toes and feet C. Patient states the feet become red if in a dependent position D. Patient reports muscle leg pain that occurs with exercise

D. Patient reports muscle leg pain that occurs with exercise Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.

Immediately after repair of an abdominal aortic aneurysm, a patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? A. Wrap both the legs in warm blankets. B. Notify the surgeon and anesthesiologist. C. Document that the pulses are absent and recheck in 30 minutes. D. Review the preoperative assessment form for data about the pulses.

D. Review the preoperative assessment form for data about the pulses. Many patients with aortic aneurysms also have peripheral arterial disease, so the nurse should check the preoperative assessment to determine whether pulses were present before surgery before notifying the health care providers about the absent pulses. Because the patient's symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 30 minutes before taking action. Warm blankets will not improve the circulation to the patient's legs.

Which action by a nurse who is administering fondaparinux (Arixtra) to a patient with venous thromboembolism (VTE) indicates that more education about the medication is needed? A. The nurse avoids rubbing the injection site after giving the medication. B. The nurse injects the medication into the abdominal subcutaneous tissue. C. The nurse fails to assess the partial thromboplastin time (PTT) before administration of the medication. D. The nurse ejects the air bubble in the syringe before administering the Arixtra

D. The nurse ejects the air bubble in the syringe before administering the Arixtra. The air bubble is not ejected before giving Arixtra. The other actions by the nurse are appropriate.

Which information will the nurse include when teaching a patient who is scheduled to have a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response? A. The pacemaker prevents or minimizes ventricular irritability. B. The pacemaker paces the atria at rates up to 500 impulses/minute. C. The pacemaker discharges if ventricular fibrillation and cardiac arrest occur. D. The pacemaker stimulates a heart beat if the patient's heart rate drops too low.

D. The pacemaker stimulates a heart beat if the patient's heart rate drops too low. The permanent pacemaker will discharge when the ventricular rate drops below the set rate. The pacemaker will not decrease ventricular irritability or discharge if the patient develops ventricular fibrillation. Since the patient has a slow ventricular rate, overdrive pacing will not be used.

Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? A. The patient rates the pain at a level 3 to 5 (0 to 10 scale). B. The patient states that the pain "wakes me up at night." C. The patient says that the frequency of the pain has increased over the last few weeks. D. The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet.

D. The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet. Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

When discussing risk factor modification for a 60-year-old patient who has a 4-cm abdominal aortic aneurysm, the nurse will focus patient teaching on which of these patient risk factors? A. Male gender B. Marfan syndrome C. Abdominal trauma history D. Uncontrolled hypertension

D. Uncontrolled hypertension All of the factors contribute to the patient's risk, but only the hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.

1/1 Several hours after an open surgical repair of an abdominal aortic aneurysm, the patient develops a urinary output of 20 mL/hr for 2 hours. The nurse notifies the health care provider and anticipates orders for A. an additional antibiotic. B. a white blood cell (WBC) count. C. a decrease in IV infusion rate. D. a blood urea nitrogen (BUN) level.

D. a blood urea nitrogen (BUN) level The decreased urine output suggests decreased renal perfusion, and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient's decreased urinary output.

A patient with an acute MI has a sinus tachycardia of 126 beats per min. The nurse recognizes that if this dysrhythmia is not treated, the patient is likely to experience A. hypertension B. escape rhythms C. ventricular tachycardia D. an increase in infarct size

D. an increase in infarct size Although many factors can cause a sinus tachycardia, in the patient who has had an acute MI, a tachycardia increases myocardial oxygen need in a heart that already has impaired circulation and may lead to increasing angina and further ischemia and necrosis.

The nurse plans close monitoring for the patient during electrophysiologic testing because this test A. requires the use of dyes that irritate the myocardium B. causes myocardial ischemia, resulting in dysrhythmias C. involves the use of anticoagulants to prevent thrombus and embolism D. induces dysrhythmias that may require cardioversion/defibrillation to correct

D. induces dysrhythmias that may require cardioversion/defibrillation to correct Electrophysiologic testing involves electrical stimulation to various areas of the atrium and ventricle to determine the inducibility of dysrhythmias and frequently induces ventricular tachycardia or ventricular fibrillation. The patient may have "near-death" experiences and requires emotional support if this occurs

Nadolol (Corgard) is prescribed for a patient with angina. To determine whether the drug is effective, the nurse will monitor for A. decreased blood pressure and apical pulse rate. B. fewer complaints of having cold hands and feet. C.improvement in the quality of the peripheral pulses. D. the ability to do daily activities without chest discomfort.

D. the ability to do daily activities without chest discomfort. Because the medication is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure (BP) and apical pulse rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective b-blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in peripheral pulse quality or skin temperature.

The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if A. the patient is restless and agitated. B. the blood pressure is 190/110 mm Hg. C. the patient complains about feeling anxious. D. the cardiac monitor shows a heart rate of 45

D. the cardiac monitor shows a heart rate of 45 Patients taking b-blockers should be monitored for bradycardia. Because this category of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects.