220 chapter 7 recap
A key aspect of teaching for the patient on anticoagulant therapy includes which instructions? a. Monitor for and report any signs of bleeding. b. Do not take acetaminophen (Tylenol) for a headache. c. Decrease your dietary intake of foods containing vitamin K. d. Arrange to have blood drawn routinely to check drug levels
a. Monitor for and report any signs of bleeding.
The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Notify the surgeon and anesthesiologist. b. Wrap both the legs in a warming blanket. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.
a. Notify the surgeon and anesthesiologist.
An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first? a. Obtain the blood pressure. b. Obtain blood for laboratory testing. c. Assess for the presence of an abdominal bruit. d. Determine any family history of kidney disease.
a. Obtain the blood pressure.
After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? "I will replace my nitroglycerin supply every 6 months." "I can take up to five tablets every 3 minutes for relief of my chest pain." "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."
"I can take up to five tablets every 3 minutes for relief of my chest pain."
In caring for the patient with angina, the patient said, "I walked to the bathroom. While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, but the pain is gone now." What further assessment data should the nurse obtain from the patient? "What precipitated the pain?" "Has the pain changed this time?" "In what areas did you feel this pain?" "Rate the pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine."
"In what areas did you feel this pain?"
A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is most appropriate? "This medication will help prevent breathing problems after surgery, such as pneumonia." "This medication will help lower your blood pressure to a safer level, which is very important after surgery." "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."
"This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal."
A patient with varicose veins has been prescribed compression stockings. Which nursing instruction would be most appropriate? "Try to keep your stockings on 24 hours a day, as much as possible." "While you're still lying in bed in the morning, put on your stockings." "Dangle your feet at your bedside for 5 minutes before putting on your stockings." "Your stockings will be most effective if you can remove them for a few minutes several times a day."
"While you're still lying in bed in the morning, put on your stockings."
A patient's cardiac rhythm is sinus bradycardia with a heart rate of 34 beats/min. If the bradycardia is symptomatic, the nurse would expect the patient to exhibit? A. Palpitations B. Hypertension C. Warm, flushed skin D. Shortness of breath
D. Shortness of breath
Which individuals would the nurse identify as having the highest risk for CAD? A 45-year-old depressed male with a high-stress job A 60-year-old male with below normal homocysteine levels A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) levels A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2
A 45-year-old depressed male with a high-stress job
Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? A 70-year-old male, with high cholesterol and hypertension A 40-year-old female with obesity and metabolic syndrome A 60-year-old male with renal insufficiency who is physically inactive A 65-year-old female with hyperhomocysteinemia and substance abuse
A 70-year-old male, with high cholesterol and hypertension
Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? A 70-yr-old man with high cholesterol and hypertension A 40-yr-old woman with obesity and metabolic syndrome A 60-yr-old man with renal insufficiency who is physically inactive A 65-yr-old woman with hyperhomocysteinemia and substance abuse
A 70-yr-old man with high cholesterol and hypertension
While performing blood pressure screening at a health fair, the nurse counsels which person as having the greatest risk for developing hypertension? A. 56-year-old man whose father died at age 62 from a stroke B. A 30-year-old female advertising agent who is unmarried and lives alone C. A 68-year-old man who uses herbal remedies to treat his enlarged prostate gland D. A 43-year-old man who travels extensively with his job and exercises only on weekends
A. 56-year-old man whose father died at age 62 from a stroke
The nurse is caring for a patient with aortic stenosis. For what should the nurse assess the patient? A. Angina B. Headache C. Weight loss D. Peripheral edema
A. Angina
Two risk factors for coronary artery disease that increases the workload of the heart and increases myocardial oxygen demand are? A. Hypertension and cigarette smoking. B. Obesity and smokeless tobacco use. C. Elevated serum lipids and diabetes mellitus. D. Physical inactivity and elevated homocysteine levels
A. Hypertension and cigarette smoking.
A patient with critical limb ischemia had peripheral artery bypass surgery to improve circulation. What nursing care should be provided on postoperative day 1? Keep patient on bed rest. Assist patient to walk several times. Have patient sit in the chair several times. Place patient on their side with knees flexed.
Assist patient to walk several times.
A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? Keep the patient on bed rest. Assist the patient with walking several times. Have the patient sit in the chair several times. Place the patient on her side with knees flexed.
Assist the patient with walking several times.
A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? Buttock, upper outer quadrant Abdomen, anterior-lateral aspect Back of the arm, 2 inches away from a mole Anterolateral thigh, with no scar tissue nearby
Abdomen, anterior-lateral aspect
A 39-yr-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? Platelet count Activated clotting time (ACT) International normalized ratio (INR) Activated partial thromboplastin time (APTT)
Activated partial thromboplastin time (APTT)
The patient comes to the ED with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerotic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? Unstable angina Acute coronary syndrome (ACS) ST-segment-elevation myocardial infarction (STEMI) Non-ST-segment-elevation myocardial infarction (NSTEMI)
Acute coronary syndrome (ACS)
A 67-yr-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? A) Patient complains of chest pain with strenuous activity. B) Patient says muscle leg pain occurs with continued exercise. C) Patient has numbness and tingling of all his toes and both feet. D) Patient states the feet become red if he puts them in a dependent position.
B) Patient says muscle leg pain occurs with continued exercise.
A patient with left sided heart failure is prescribed oxygen at 4 L/min per nasal cannula, furosemide (Lasix), spironolactone (Aldactone), and enalapril (vasotec). Which assessment should the nurse complete to best evaluate the patient's response to these? A. Observe skin turgor B. Auscultate lung sounds C. Measure blood pressure D. Review intake and output
B. Auscultate lung sounds
The homecare nurse visits a patient with chronic heart failure who is taking digoxin (Lanoxin) and furosemide (Lasix). The patient complains of nausea and vomiting. Which action is the most appropriate for the nurse to take? A. Perform a dipstick urine test for protein. B. Notify the health care provider immediately. C. Have the patient eat foods high in potassium. D. Ask the patient to record a weight every morning
B. Notify the health care provider immediately.
The most significant factor in long term survival of a patient with sudden cardiac death is? A. Absence of underlying heart disease. B. Rapid institution of emergency services and procedures. C. Performance of perfect technique in resuscitation procedures. D. Maintenance of 50% of normal cardiac output during resuscitation efforts.
B. Rapid institution of emergency services and procedures.
The nurse teaches a patient with peripheral arterial disease. The nurse determines that further teaching is needed if the patient makes which statement? A. "I should not use heating pads to warm my feet." B. "I will examine my feet every day for any sores or red areas." C. "I should cut back on my walks if they cause pain in my legs." D. "I think I can quit smoking with the use of short-term nicotine replacement and support groups."
C. "I should cut back on my walks if they cause pain in my legs."
A patient is receiving a drug that decreases afterload. To evaluate the patient's response to this drug, what is most important for the nurse to assess? A. Heart Rate B. Lung sounds C. Blood pressure D. Jugular vein distension
C. Blood pressure
A patient's BP has not responded consistently to prescribed drugs for hypertension. The first cause of this lack of responsiveness the nurse should explore is? A. Progressive target organ damage B. The possibility of drug interactions. C. The patient not adhering to therapy. D. The patient's possible use of recreational drugs
C. The patient not adhering to therapy.
Match the lab values CRP Cholesterol HDL LDL Troponin CPK Sodium Potassium platelets 1) <200 2) detectable within hours (average, 4 to 6 hours), peaks at 10 to 24 hours, and can be detected for up to 10 to 14 days. T <0.2; I <0.03 3) 135-145 4) 6.8-820 5) >40 6) <130 7) 10-120 8) 3.5-5 9) 150,000 to 450,000
CRP - 6.8-820 Cholesterol <200 HDL - >40 LDL - <130 troponin - •detectable within hours (average, 4 to 6 hours), peaks at 10 to 24 hours, and can be detected for up to 10 to 14 days. T <0.2; I <0.03 CPK - 10-120 Sodium - 135-145 Potassium - 3.5-5 platelets 150,000 to 450,000
The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? Decreased cardiac output Increased blood pressure Cerebral or pulmonary emboli Excessive bleeding from incision or IV sites
Cerebral or pulmonary emboli
Following an aortic aneurysm repair, the patient suddenly develops severe pain in the right lower extremity. The right pedal pulse is decreased and the right foot is cool and pale. Which complication should the nurse suspect? A. hypothermia. B. a wound infection. C. Bleeding from the graft site D. An embolization or graft occlusion
D. An embolization or graft occlusion
The nurse is providing teaching to a patient recovering from an MI. How should resumption of sexual activity be discussed? Delegated to the primary care provider Discussed along with other physical activities Avoided because it is embarrassing to the patient Accomplished by providing the patient with written material
Discussed along with other physical activities
When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? Duplex ultrasound Contrast venography Magnetic resonance venography Computed tomography venography
Duplex ultrasound
A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? Tamponade will soon occur. The renal arteries are involved. Perfusion to the legs is impaired. He is bleeding into the abdomen.
He is bleeding into the abdomen.
A 32-yr-old woman is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the effectiveness of the medication, which assessment will the nurse perform? Improved skin turgor Decreased cardiac rate Improved finger perfusion Decreased mean arterial pressure
Improved finger perfusion
The nurse assesses the right femoral artery puncture site as soon as the patient arrives after having a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? Palpate the insertion site for induration. Assess peripheral pulses in the right leg. Inspect the patient's right side and back. Compare the color of the left and right legs.
Inspect the patient's right side and back.
The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? Spread the skin before inserting the needle. Leave the air bubble in the prefilled syringe. Use the back of the arm as the preferred site. Sit the patient at a 30-degree angle before administration
Leave the air bubble in the prefilled syringe.
Which assessment finding would alert the nurse that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox)? Crackles bilaterally in the lung bases Pain and swelling in a lower extremity Absence of arterial pulse in a lower extremity Abdominal pain with decreased bowel sounds
Pain and swelling in a lower extremity
A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? Paralysis Paresthesia Cramping Referred pain
Paresthesia
The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? Hematocrit (Hct) Hemoglobin (Hgb) Prothrombin time (PT) Partial thromboplastin time (PTT)
Prothrombin time (PT)
Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? Remove the patient's IV catheter. Apply an ice pack to the affected area. Decrease the IV rate to 20 to 30 mL/hr. Administer prophylactic anticoagulants.
Remove the patient's IV catheter.
The patient has chronic venous insufficiency and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what patients 'always' have ordered. Which assessment finding would indicate the application of compression stockings could harm the patient? Rest pain High blood pressure Elevated blood sugar Dry, itchy, flaky skin
Rest pain
A 62-yr-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker with a history of gout. To prevent complications, which factor is priority in patient teaching? Gender Smoking Ethnicity Comorbidities
Smoking
What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? Application of topical antibiotics to venous ulcers Maintaining the patient's legs in a dependent position Administration of oral and/or subcutaneous anticoagulants Teaching the patient the correct use of compression stockings
Teaching the patient the correct use of compression stockings
The patient had aortic aneurysm repair 6 hours ago. What priority nursing action will maintain graft patency? Assess output for renal dysfunction. Use IV fluids to maintain adequate BP. Use oral antihypertensives to maintain cardiac output. Maintain a low BP to prevent pressure on surgical site.
Use IV fluids to maintain adequate BP.
The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequela? Pulmonary embolism Pulmonary hypertension Post-thrombotic syndrome Venous thromboembolism
Venous thromboembolism
The nurse is admitting a 68-yr-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? Vitamin K Cobalamin Heparin sodium Protamine sulfate
Vitamin K
The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which ethnic group would the nurse select as the highest priority for this intervention? White male Hispanic male African American male Native American female
White male
A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnosis? a. "I can't get my shoes on at the end of the day." b. "I can't seem to ever get my feet warm enough." c. "I have burning leg pains after I walk two blocks." d. "I wake up during the night because my legs hurt."
a. "I can't get my shoes on at the end of the day."
A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of medications will the nurse plan to include when providing patient teaching about PAD management? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants
a. Statins
After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which action by the patient demonstrates that the teaching has been effective? a. The patient exercises indoors during the winter months. b. The patient places the hands in hot water when they turn pale. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).
a. The patient exercises indoors during the winter months.
A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of a. echocardiography. b. daily blood cultures. c. cardiac catheterization. d. 24-hour Holter monitor.
a. echocardiography.
The nurse is developing a discharge teaching plan for a patient diagnosed with thromboangiitis obliterans (Buerger's disease). Which expected outcome has the highest priority for this patient? a.Cessation of all tobacco use b.Control of serum lipid levels c.Maintenance of appropriate weight d.Demonstration of meticulous foot care
a.Cessation of all tobacco use
A patient who has chest pain is admitted to the emergency department (ED), and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first? a.Electrocardiogram (ECG) b.Computed tomography (CT) scan c.Chest x-ray d.Troponin level
a.Electrocardiogram (ECG)
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
Four days after having a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with all the daily activities, saying, I am too nervous to take care of myself. Based on this information, which nursing diagnosis is appropriate? a.Ineffective coping related to anxiety b.Activity intolerance related to weakness c.Denial related to lack of acceptance of the MI d.Social isolation related to lack of support system
a.Ineffective coping related to anxiety
Which information about a patient who has been receiving fibrinolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider? a.No change in the patients chest pain b.A large bruise at the patients IV insertion site c.A decrease in ST segment elevation on the electrocardiogram (ECG) d.An increase in cardiac enzyme levels since admission
a.No change in the patients chest pain
A patient who is being admitted to the emergency department with severe chest pain gives the following list of medications taken at home to the nurse. Which of the medications has the most immediate implications for the patients care? a.sildenafil (Viagra) b.furosemide (Lasix) c.diazepam (Valium) d.captopril (Capoten)
a.sildenafil (Viagra)
The first priority of collaborative care of a patient with a suspected acute aortic dissection is to a. reduce anxiety. b. control blood pressure. c. monitor for chest pain. d. increase myocardial contractility
b. control blood pressure.
The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following? a. "I should get a Medic Alert device stating that I take Coumadin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the Coumadin." d. "I will check with my health care provider before I begin any new medications."
b. "I should reduce the amount of green, leafy vegetables that I eat."
When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."
b. "It is very important that you stop smoking cigarettes."
Which of these patients admitted to the emergency department should the nurse assess first? a. 62-year-old who has gangrenous ulcers on both feet b. 50-year-old who is complaining of tearing chest pain c. 45-year-old who is taking anticoagulants and has bloody stools d. 36-year-old who has right calf tenderness, redness, and swelling
b. 50-year-old who is complaining of tearing chest pain
Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism? a. Monitor for any bleeding after anticoagulation therapy is started. b. Apply sequential compression device whenever the patient is in bed. c. Ask the patient about use of herbal medicines or dietary supplements. d. Instruct the patient to call immediately if any shortness of breath occurs.
b. Apply sequential compression device whenever the patient is in bed.
Which nursing action should 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 incision for any redness. d. Teach the reason for a prolonged recovery period.
b. Monitor fluid intake and urine output.
The nurse is 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 perform first? a. Begin oral intake. b. Obtain vital signs. c. Assess pedal pulses. d. Start discharge teaching.
b. Obtain vital signs.
The nurse who works in the vascular clinic has several patients with venous insufficiency scheduled today. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Patient who has been complaining of increased edema and skin changes in the legs b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg c. Patient who has a history of venous thromboembolism and is complaining of some dyspnea d. Patient who needs teaching about the use of elastic compression stockings for venous insufficiency
b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg
A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that his aneurysm has ruptured? a. Sudden shortness of breath and hemoptysis b. Sudden, severe low back pain and bruising along his flank c. Gradually increasing substernal chest pain and diaphoresis d. Sudden, patchy blue mottling on feet and toes and rest pain
b. Sudden, severe low back pain and bruising along his flank
The health care provider prescribes an infusion of heparin (Hep-Lock) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to a. decrease the infusion when the PTT value is 65 seconds. b. avoid giving any IM medications to prevent localized bleeding. c. monitor posterior tibial and dorsalis pedis pulses with the Doppler. d. have vitamin K available in case reversal of the heparin is needed.
b. avoid giving any IM medications to prevent localized bleeding.
When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will a. have to buy some loose clothes that do not bind across my legs or waist." b. use a heating pad on my feet at night to increase the circulation and warmth in my feet." c. change my position every hour and avoid long periods of sitting with my legs crossed." d. walk to the point of pain, rest, and walk again until the pain returns for at least 30 minutes 3 times a week."
b. use a heating pad on my feet at night to increase the circulation and warmth in my feet."
When admitting a patient with a myocardial infarction (MI) to the intensive care unit, which action should the nurse carry out first? a.Obtain the blood pressure. b.Attach the cardiac monitor. c.Assess the peripheral pulses. d.Auscultate the breath sounds.
b.Attach the cardiac monitor.
A patient who has had an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best? a.Most patients are able to enjoy intercourse without any complications. b.Sexual activity uses about as much energy as climbing two flights of stairs. c.The doctor will discuss sexual intercourse when your heart is strong enough. d.Holding and cuddling are good ways to maintain intimacy after a heart attack.
b.Sexual activity uses about as much energy as climbing two flights of stairs.
Which information collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction (AMI)? a.The pain increases with deep breathing. b.The pain has persisted longer than 30 minutes. c.The pain worsens when the patient raises the arms. d.The pain is relieved after the patient takes nitroglycerin.
b.The pain has persisted longer than 30 minutes.
A few days after experiencing a myocardial infarction (MI), the patient states, I just had a little chest pain. As soon as I get out of here, Im going for my vacation as planned. Which response should the nurse make? a.Where are you planning to go for your vacation? b.What do you think caused your chest pain episode? c.Sometimes plans need to change after a heart attack. d.Recovery from a heart attack takes at least a few weeks.
b.What do you think caused your chest pain episode?
A patient with ST segment elevation in several electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? a.Do you take aspirin on a daily basis? b.What time did your chest pain begin? c.Is there any family history of heart disease? d.Can you describe the quality of your chest pain?
b.What time did your chest pain begin?
When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient a.that sudden cardiac death events rarely reoccur. b.about the purpose of outpatient Holter monitoring. c.how to self-administer low-molecular-weight heparin. d.to limit activities after discharge to prevent future events.
b.about the purpose of outpatient Holter monitoring.
Amlodipine (Norvasc) is ordered for a patient with newly diagnosed Prinzmetals (variant) angina. When teaching the patient, the nurse will include the information that amlodipine will a.reduce the fight or flight response. b.decrease spasm of the coronary arteries. c.increase the force of myocardial contraction. d.help prevent clotting in the coronary arteries.
b.decrease spasm of the coronary arteries.
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.
A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most appropriate? a. "Taking two blood thinners reduces the risk for another clot to form." b. "Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from forming." c. "Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots." d. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner."
c. "Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots."
After receiving report, which patient admitted to the emergency department should the nurse assess first? a. 67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse b. 58-year-old who is taking anticoagulants for atrial fibrillation and has black stools c. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain d. 39-year-old who has right calf tenderness, redness, and swelling after a long plane ride
c. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain
The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure 137/88 mm Hg d. 25 mL urine output over last hour
c. Blood pressure 137/88 mm Hg
A 46-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge? a. Sitting at the work counter, rather than standing, is recommended. b. Exercise, such as walking or jogging, can cause recurrence of varicosities. c. Elastic compression stockings should be applied before getting out of bed. d. Taking an aspirin daily will help prevent clots from forming around venous valves.
c. Elastic compression stockings should be applied before getting out of bed.
Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Erythema of right lower leg b. Complaint of right calf pain c. New onset shortness of breath d. Temperature of 100.4° F (38° C)
c. New onset shortness of breath
Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that more education about the drug is needed? a. The nurse avoids rubbing the injection site after giving the drug. b. The nurse injects the drug into the abdominal subcutaneous tissue. c. The nurse ejects the air bubble in the syringe before giving the drug. d. The nurse fails to assess the partial thromboplastin time (PTT) before giving the drug.
c. The nurse ejects the air bubble in the syringe before giving the drug.
Priority nursing measures after an abdominal aortic aneurysm repair include a. assessment of cranial nerves and mental status. b. administration of IV heparin and monitoring of aPTT. c. administration of IV fluids and monitoring of kidney function. d. elevation of the legs and application of elastic compression stockings.
c. administration of IV fluids and monitoring of kidney function.
A 23-year-old patient tells the health care provider about experiencing cold, numb fingers when running during the winter and Raynaud's phenomenon is suspected. The nurse will anticipate teaching the patient about tests for a. hyperglycemia. b. hyperlipidemia. c. autoimmune disorders. d. coronary artery disease.
c. autoimmune disorders.
A patient with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. The nurse's initial action should be to a. elevate the leg to promote venous return. b. start anticoagulant therapy with IV heparin. c. notify the physician of the change in peripheral perfusion. d. place the bed in reverse Trendelenburg to promote perfusion.
c. notify the physician of the change in peripheral perfusion.
The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find a. dilated superficial veins. b. swollen, dry, scaly ankles. c. prolonged capillary refill in all the toes. d. a serosanguineous drainage from the ulcer.
c. prolonged capillary refill in all the toes.
A 50-year-old woman weighs 95 kg and has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that need to be modified are a. weight and diet. b. activity level and diet. c. tobacco use and high blood pressure. d. sedentary lifestyle and high blood pressure.
c. tobacco use and high blood pressure.
The nurse has just received change-of-shift report about the following four patients. Which patient should the nurse assess first? a.38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain b.45-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge c.51-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI) d.60-year-old with variant angina who is to receive a scheduled dose of nifedipine (Procardia)
c.51-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)
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.
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.
A patient who has had severe chest pain for several hours is admitted with a diagnosis of possible acute myocardial infarction (AMI). Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an AMI? a.Homocysteine b.C-reactive protein c.Cardiac-specific troponin I and troponin T d.High-density lipoprotein (HDL) cholesterol
c.Cardiac-specific troponin I and troponin T
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
Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patients response, which of these assessment data would indicate that the exercise level should be decreased? a.BP changes from 118/60 to 126/68 mm Hg. b.Oxygen saturation drops from 100% to 98%. c.Heart rate increases from 66 to 90 beats/minute. d.Respiratory rate goes from 14 to 22 breaths/minute.
c.Heart rate increases from 66 to 90 beats/minute.
After the nurse has finished teaching a patient about use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a.I can expect indigestion as a side effect of nitroglycerin. b.I can only take the nitroglycerin if I start to have chest pain. c.I will call an ambulance if I still have pain 5 minutes after taking the nitroglycerin. d.I will help slow down the progress of the plaque formation by taking nitroglycerin.
c.I will call an ambulance if I still have pain 5 minutes after taking the nitroglycerin.
Which assessment finding by the nurse who is caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the physician? a.Complaints of incisional chest pain b.Crackles audible at both lung bases c.Pallor and weakness of the right hand d.Redness on either side of the chest incision
c.Pallor and weakness of the right hand
During the administration of the fibrinolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences a.bleeding from the gums. b.surface bleeding from the IV site. c.a decrease in level of consciousness. d.a nonsustained episode of ventricular tachycardia.
c.a decrease in level of consciousness.
While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information? a. "When I stand too long, my feet start to swell." b. "I get short of breath when I climb a lot of stairs." c. "My fingers hurt when I go outside in cold weather." d. "My legs cramp whenever I walk more than a block."
d. "My legs cramp whenever I walk more than a block."
Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg? a. Need to increase carbohydrate intake b. Methods of keeping the wound area dry c. Purpose of prophylactic antibiotic therapy d. Application of elastic compression stockings
d. Application of elastic compression stockings
Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.
d. Help the patient to use a pillow to splint while coughing.
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patient's feet is best? a. The patient is placed in the Trendelenburg position. b. Two pillows are positioned under the affected leg. c. The bed is elevated at the knee and pillows are placed under the feet. d. One pillow is placed under the thighs and two pillows are placed under the lower legs.
d. One pillow is placed under the thighs and two pillows are placed under the lower legs.
When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension
d. Uncontrolled hypertension
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.
In planning care and patient teaching for the patient with venous leg ulcers, the nurse recognizes that the most important intervention in healing and control of this condition is a. sclerotherapy. b. using moist environment dressings. c. taking horse chestnut seed extract daily. d. applying elastic compression stockings
d. applying elastic compression stockings
A patient at the clinic says, "I have always taken a walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though." The nurse should a. check for the presence of tortuous veins bilaterally on the legs. b. ask about any skin color changes that occur in response to cold. c. assess for unilateral swelling, redness, and tenderness of either leg. d. assess for the presence of the dorsalis pedis and posterior tibial pulses.
d. assess for the presence of the dorsalis pedis and posterior tibial pulses.
A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately a. apply a compression stocking to the leg. b. elevate the leg above the level of the heart. c. assist the patient in gently exercising the leg. d. keep the patient in bed in the supine position.
d. keep the patient in bed in the supine position.
The recommended treatment for an initial VTE in an otherwise healthy person with no significant co-morbidities would include a. IV argatroban (Acova) as an inpatient. b. IV unfractionated heparin as an inpatient. c. subcutaneous unfractionated heparin as an outpatient. d. subcutaneous low-molecular-weight heparin as an outpatient
d. subcutaneous low-molecular-weight heparin as an outpatient
When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing action should the nurse delegate to an LPN/LVN? a.Perform the initial assessment of the catheter insertion site. b.Teach the patient about the usual postprocedure plan of care. c.Check the rate on the infusion pump used to administer heparin. d.Administer the scheduled aspirin and lipid-lowering medication.
d.Administer the scheduled aspirin and lipid-lowering medication.
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.
When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having balloon angioplasty, the nurse obtains the following assessment data. Which data indicate the need for immediate intervention by the nurse? a.Pedal pulses 1+ b.Heart rate 100 beats/min c.Blood pressure 104/56 mm Hg d.Chest pain level 8 on a 10-point scale
d.Chest pain level 8 on a 10-point scale
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.
A patient with a nonST-segment-elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? a.Platelet aggregation is enhanced by IV heparin infusion. b.Heparin will dissolve the clot that is blocking blood flow to the heart. c.Coronary artery plaque size and adherence are decreased with heparin. d.Heparin will prevent the development of new clots in the coronary arteries.
d.Heparin will prevent the development of new clots in the coronary arteries.
After the nurse teaches a patient with chronic stable angina about how to use the prescribed short-acting and long-acting nitrates, which statement by the patient indicates that the teaching has been effective? a.I will put on the nitroglycerin patch as soon as I develop any chest pain. b.I will check the pulse rate in my wrist just before I take any nitroglycerin. c.I will be sure to remove the nitroglycerin patch before using any sublingual nitroglycerin. d.I will stop what I am doing and sit down before I put the nitroglycerin under my tongue.
d.I will stop what I am doing and sit down before I put the nitroglycerin under my tongue.
Which of these nursing interventions included in the plan of care for a patient who had an acute myocardial infarction (AMI) 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN? a.Evaluating the patients response to ambulation in the hallway b.Completing the documentation for a home health nurse referral c.Educating the patient about the pathophysiology of heart disease d.Reinforcing teaching about the purpose of prescribed medications
d.Reinforcing teaching about the purpose of prescribed medications
Which electrocardiographic (ECG) change is most important for the nurse to communicate to the health care provider when caring for a patient with chest pain? a.Frequent premature atrial contractions (PACs) b.Inverted P wave c.Sinus tachycardia d.ST segment elevation
d.ST segment elevation
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.
When developing a health teaching plan for a 60-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the a.family history of coronary artery disease. b.increased risk associated with the patients gender. c.high incidence of cardiovascular disease in older people. d.elevation of the patients serum low density lipoprotein (LDL) level.
d.elevation of the patients serum low density lipoprotein (LDL) level.
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.
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.