Questions
A client with suspected acute myocardial infarction is admitted to the coronary care unit. To help confirm the diagnosis, the physician orders serial enzyme tests. Increased serum levels of the isoenzyme creatinine kinase of myocardial muscle (CK-MB), found only in cardiac muscle, can be detected how soon after the onset of chest pain? a) 2 to 3 hours b) 12 to 18 hours c) 4 to 6 hours d) 30 minutes to 1 hour
4 to 6 hours Explanation: Serum CK-MB levels can be detected 4 to 6 hours after the onset of chest pain. These levels peak within 12 to 18 hours and return to normal within 3 to 4 days.
The nurse is instructing a client who is at risk for peripheral vascular disease how to use knee length elastic stockings (support hose). The teaching plan should include which of the following? Check all that apply. a) Apply the stockings while in bed. b) Once the stockings have been pulled over the calf, roll the remaining stocking down to make a cuff. c) Remove the stockings if swelling occurs. d) Apply the elastic stockings in the morning. e) Keep the stockings in place for 48 hours and reapply using a clean pair of stockings.
Elastic stockings (support hose) are used to promote circulation by preventing pooling of blood in the feet and legs. The stockings should be applied in the morning before the client gets out of bed. The stockings should be applied smoothly and to avoid wrinkles, but the top should not be rolled down to avoid constriction of circulation. The stockings should be removed every 8 hours and the client should elevate the legs for 15 minutes and reapply the stockings. Clean stockings should be applied daily or as needed.
The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should: a) Assess the client for foot ulcers. b) Suggest the client contact her physcian. c) Apply a half-leg pneumatic compression device. d) Encourage the client to avoid standing in one position for long periods of time.
Encourage the client to avoid standing in one position for long periods of time. Explanation: The client has varicose veins which are evident by the tortuous, distended veins where blood has pooled. To prevent pooling of the blood, the client should not stand in one place for long periods of time. It is not necessary to use compression devices, but the client could wear support hose if she stands for long periods of time. The client can consider cosmetic surgery to remove the distented veins, but there is not indication that the client should contact the physician at this point in time. The nurse can inspect the client's feet, but the client is not at risk for ulcers at this time. (less)
A client arrives at the emergency department with severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. Suddenly, the client collapses and becomes unresponsive. What is the priority action by the nurse? a) Maintain an open airway. b) Initiate chest compressions before ventilations. c) Activate the emergency response team. d) Initiate ventilations before chest compressions.
Initiate chest compressions before ventilations. Explanation: This is according to current standards by the American heart and stroke associations (Heart and Stroke Foundation of Canada). The other choices are all in sequence at some point of resuscitation, but current standards are to initiate chest compression, then ventilation.
A client with end-stage heart failure is preparing for discharge. The client and his caregiver meet with the home care nurse and voice their concern that setting up a hospital bed in the bedroom will leave him feeling isolated. Which suggestion by the home care nurse best addresses this concern? a) Set up the hospital bed in the bedroom so the client can be assessed in a quiet environment. b) Place a chair in the bedroom so guests can visit with the client. c) Set up the hospital bed in the bedroom so the client can rest in a quiet environment. d) Set up the hospital bed in the family room so the client can be part of household activities
Set up the hospital bed in the family room so the client can be part of household activities. Explanation: The client should be kept actively involved in the household to prevent feelings of isolation. This can be accomplished by setting up the hospital bed in the family room. Placing a chair in the bedroom allows the client periods of isolation when visitors aren't present. It's important for the client to have periods of rest; however, rest can be accomplished without keeping the client isolated in a bedroom. The needs of the client should be considered before the needs of the nurse who assesses the client during an occasional visit.
A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: a) Showing the location of the obstruction and the collateral circulation. b) Scanning the affected extremity and identifying the areas of volume changes. c) Determining how long the client can walk. d) Using ultrasound to estimate the velocity changes in the blood vessels.
Showing the location of the obstruction and the collateral circulation. Explanation: An arteriogram involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels. It usually involves computed tomographic scanning. The velocity of the blood flow can be estimated by duplex ultrasound. The client's ankle-brachial index is determined, and then the client is requested to walk. The normal response is little or no drop in ankle systolic pressure after exercise.
A nurse just received a shift report for a group of clients on the telemetry unit. Which client should the nurse assess first? a) The client with a history of cardioversion for sustained ventricular tachycardia 2 days ago b) The client with a history of heart failure who has bibasilar crackles and pitting edema in both feet c) The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block d) The client admitted for unstable angina who underwent percutaneous coronary intervention (PCI) with stenting yesterday
The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block Correct Explanation: The client whose cardiac rhythm now shows type II second-degree AV block should be assessed first. The client's rhythm has deteriorated from first-degree heart block to type II second-degree AV block and may continue to deteriorate into a lethal form of AV block (known as complete heart block). The client who underwent cardioversion 2 days ago has likely had the underlying reason for the sustained ventricular tachycardia corrected. The client with a history of heart failure may have chronic bibasilar crackles and pitting edema of both feet. Therefore, assessing this client first is not necessary. The client who underwent PCI with stenting was at risk for reperfusion arrhythmias and/or bleeding from the arterial puncture site but could be considered to be stable 24 hours post procedure.
The client with vasospastic disorder (Raynaud's phenomenon) has coldness and numbness in the fingers. The nurse assesses the client for effects of vasoconstriction. Which of the following is an early sign of vasoconstriction? a) Pallor. b) Gangrene. c) Rubor. d) Cyanosis.
a) Pallor. Initially the vasoconstriction effect produces pallor or a whitish coloring, followed by cyanosis (bluish) and finally rubor (red). Gangrene is the end result of complete arterial occlusion; the skin is blackened and without a blood supply.
A fourth heart sound (S4) indicates a: a) decreased myocardial contractility. b) dilated aorta. c) failure of the ventricle to eject all blood during systole. d) normally functioning heart.
failure of the ventricle to eject all blood during systole. Correct Explanation: An S4 occurs as a result of increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased ventricular compliance. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. A nurse hears decreased myocardial contractility as a third heart sound. She doesn't hear an S4 in a normally functioning heart.
