Cardiac NCLEX
A patient with a history rheumatic heart disease knows that she is at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the patient knows the importance of taking which of the following drugs? A. Amoxicillin (Amoxil) B. Metoprolol (Lopressor) C. Enoxaparin (Lovenox) D. Azathioprine (Imuran)
A. Amoxicillin (Amoxil) Although rare, bacterial endocarditis may be life-threatening. A key strategy is primary prevention in high-risk patients (i.e., those with rheumatic heart disease, mitral valve prolapse, or prosthetic heart valves). Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after certain procedures. Amoxicillin is the drug of choice. None of the other listed drugs is an antibiotic.
A nurse is caring for a patient who has been scheduled for a bone scan. What should the nurse teach the patient about this diagnostic test? A. "You'll be encouraged to drink water after the administration of the radioisotope injection." B. "This is a common test that can be safely performed on anyone." C. "You will not be allowed fluid for 2 hours before and 3 hours after the test." D. "The test is brief and requires that you drink a calcium solution 2 hours before the test."
A. "You'll be encouraged to drink water after the administration of the radioisotope injection." It is important to encourage the patient to drink plenty of fluids to help distribute and eliminate the isotopic after it is injected. There are important contraindications to the procedure, include pregnancy or an allergy to the radioisotope. The test requires the injection of an intravenous radioisotope and the scan is preformed 2 to 3 hours after the isotope is injected. A calcium solution is not utilized.
A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? A. Absence seizure B. Focal seizure C. Generalized seizure D. Unclassified seizure
A. Absence seizure Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patient's plan of care? A. Administration of thorough oral hygiene B. Fluid restriction as ordered C. Administration of a low-protein diet D. Monitoring of pulse oximetry
A. Administration of thorough oral hygiene Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin) use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring.
An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply. A. Adverse medication effects B. Loss of visual acuity C. Muscle weakness D. Slowed reflexes E. Hearing loss
A. Adverse medication effects B. Loss of visual acuity C. Muscle weakness D. Slowed reflexes Older adults are generally vulnerable to falls and have a high incidence of hip fracture. Weak quadriceps muscles, medication effects, vision loss, and slowed reflexes are among the factors that contribute to the incidence of falls. Decreased hearing is not noted to contribute to the incidence of falls.
A nurse is caring for a patient with a diagnosis of cancer that has metastasized. What laboratory value would the nurse expect to be elevated in this patient? A. Alkaline phosphatase B. Bilirubin C. Potassium D. Creatinine
A. Alkaline phosphatase Alkaline phosphatase is elevated during early fracture healing and in diseases with increased osteoblastic activity (e.g., metastatic bone tumors). Elevated bilirubin, potassium, and creatinine would not be expected in a patient with metastatic bone tumors.
The nurse is providing discharge teaching for a patient who developed a pulmonary embolism after total knee surgery. The patient has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client? A. Anticoagulant therapy usually lasts between 3 and 6 months. B. Coumadin must be taken concurrent with ASA to achieve anticoagulation. C. Coumadin will continue to break up the clot over a period of weeks D. He should take a vitamin supplement containing vitamin K
A. Anticoagulant therapy usually lasts between 3 and 6 months. Anticoagulant therapy prevents further clot formation, but cannot be used to dissolve a clot. The therapy continues for approximately 3 to 6 months and is not combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and normally should not be taken.
The nurse is reviewing a newly admitted patient's electronic health record, which notes a history of orthopnea? What nursing action is most clearly indicated? A. Avoid positioning the patient supine. B. Limit the patient's activity level. C. Teach the patient deep breathing and coughing exercises. D. Administer supplemental oxygen at all times.
A. Avoid positioning the patient supine. Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of HF and, consequently, the nurse should avoid positioning the patient supine. Oxygen supplementation may or may not be necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly address this symptom.
A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA. For what complication should the nurse most closely monitor the patient? A. Bleeding at insertion site B. Congestive heart failure C. Left ventricular hypertrophy D. Hyperlipidemia
A. Bleeding at insertion site Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include hyperlipidemia, left ventricular hypertrophy, or congestive heart failure; each of these problems takes an extended time to develop and none is emergent.
The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply. A. Bleeding at the insertion site B. Venous insufficiency C. Retroperitoneal bleeding D. Abrupt closure of the coronary artery E. Arterial occlusion
A. Bleeding at the insertion site C. Retroperitoneal bleeding D. Abrupt closure of the coronary artery E. Arterial occlusion Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute renal failure. Venous insufficiency is not a postprocedure complication of a PTCA.
A patient with HF has met with his primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment? A. Blood pressure B. Level of consciousness (LOC) C. Oxygen saturation D. Assessment for nausea
A. Blood pressure Patients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must be monitored in patients with HF, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause nausea.
A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse recognizes that the patient has likely sustained what? A. Contusion B. Sprain C. Strain D. Dislocation
A. Contusion A contusion is a soft-tissue injury that results in bleeding into soft tissues, creating a hematoma and ecchymosis. A sprain is an injury to ligaments caused by wrenching or twisting. A strain is a "muscle pull" from overuse, overstretching, or excessive stress. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact. Because the injury is not at the site of a joint, the patient has not experienced a sprain, strain, or dislocation.
The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patient's diagnosis? A. Distended neck veins B. Dry cough C. Pulmonary edema D. Orthopnea
A. Distended neck veins Right-sided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers do not apply.
A nurse in a busy emergency department provides care for many patients who present with contusions, strains, or sprains. Treatment modalities that are common to all of these musculoskeletal injuries include which of the following? Select all that apply. A. Elevating the injured limb B. Compression dressings C. Resting the affected extremity D. Corticosteroids CorrectE. Applying ice F. Massage
A. Elevating the injured limb B. Compression dressings C. Resting the affected extremity Treatment of contusions, strains, and sprains consists of resting and elevating the affected part, applying cold, and using a compression bandage. Massage and corticosteroids are not used to treat these injuries.
A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A. Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists. B. Obtain an order for a sedative, such as lorazepam (Ativan), to prevent the patient from scratching. C. Allow the patient to continue to scratch inside the cast with a pencil but encourage him to be cautious. D. Give the patient a sterile tongue depressor to use for scratching instead of the pencil.
A. Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists Scratching should be discouraged because of the risk for skin breakdown or damage to the cast. Most patients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Benzodiazepines would not be given for this purpose.
The nurse is creating a plan of care for a patient diagnosed with acute laryngitis. What intervention should be included in the patient's plan of care? A. Encourage the patient to limit speech whenever possible. B. Have the patient inhale warm steam three times daily. C. Limit the patient's fluid intake to 1.5 L/day. D. Place warm cloths on the patient's throat, as needed.
A. Encourage the patient to limit speech whenever possible Management of acute laryngitis includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool steam or an aerosol. Fluid intake should be increased. Warm cloths on the throat will not help relieve the symptoms of acute laryngitis.
A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals? A. Encouraging the patient to turn from side to side and to assume a prone position B. Minimizing movement of the flexor muscles of the hip C. Encouraging the patient to sit in a chair for at least 8 hours a day D. Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation
A. Encouraging the patient to turn from side to side and to assume a prone position The nurse encourages the patient to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early, because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for patients with BKAs. The nurse also discourages sitting for prolonged periods of time.
A nurse is caring for a patient who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure? A. Ensuring that there are no metal objects on or in the patient B. Ensuring that the patient can remain immobile for up to 3 hours C. Assessing the patient for a history of nut allergies D. Assessing the patient for signs and symptoms of active infection
A. Ensuring that there are no metal objects on or in the patient Absolutely no metal objects can be present during MRI—their presence constitutes a serious safety risk. The procedure takes up to 90 minutes. Nut allergies and infection are not contraindications to MRI.
As a clinic nurse, you are caring for a patient who has been prescribed an antibiotic for tonsillitis and has been instructed to take the antibiotic for 10 days. When you do a follow-up call with this patient, you are informed that the patient is feeling better and is stopping the medication after taking it for 4 days. What information should you provide to this patient? A. Finish all the antibiotics to eliminate the organism completely. B. Keep the remaining tablets for an infection at a later time. C. Discontinue the medications if the fever is gone. D. Dispose of the remaining medication in a biohazard receptacle.
A. Finish all the antibiotics to eliminate the organism completely. The nurse informs the patient about the need to take the full course of any prescribed antibiotic. Antibiotics should be taken for the entire 10-day period to eliminate the microorganisms. A patient should never be instructed to keep leftover antibiotics for use at a later time. Even if the fever or other symptoms are gone, the medications should be continued. Antibiotics do not need to be disposed of in a biohazard receptacle, though they should be discarded appropriately.
Radiographs of a boy's upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture? A. Greenstick B. Impacted C. Compression D. Compound
A. Greenstick Greenstick fractures are an incomplete fracture that results in the bone being broken on one side, while the other side is bent. This is not characteristic of an impacted, compound, or compression fracture.
You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication? A. Increased muscle strength B. Improved cognition C. Improved GI function D. Decreased pain
A. Increased muscle strength The goal of treatment using pyridostigmine bromide is improvement of muscle strength and control of fatigue. The drug is not intended to treat pain, or cognitive or GI functions.
The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly patients with MS are known to be particularly concerned about what variables? Select all that apply. A. Increasing disability B. Becoming a burden on the family C. Loss of appetite D. Possible nursing home placement E. Pain associated with physical therapy
A. Increasing disability B. Becoming a burden on the family D. Possible nursing home placement Elderly patients with MS are particularly concerned about increasing disability, family burden, marital concern, and the possible future need for nursing home care. Older adults with MS are not noted to have particular concerns regarding the pain of therapy or loss of appetite.
A nurse is preparing a patient for scheduled transesophageal echocardiography. What action should the nurse perform? A. Inform the patient that she will remain on bed rest following the procedure. B. Instruct the patient to drink 1 liter of water before the test. C. Inform the patient that an access line will be initiated in her femoral artery. D. Administer IV benzodiazepines and opioids.
A. Inform the patient that she will remain on bed rest following the procedure. During the recovery period, the patient must maintain bed rest with the head of the bed elevated to 45 degrees. The patient must be NPO 6 hours preprocedure. The patient is sedated to make him or her comfortable, but will not be heavily sedated, and opioids are not necessary. Also, the patient will have a peripheral IV line initiated preprocedure.
A nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage which of the following? A. Keep an elastic compression bandage on the ankle. B. Apply heat for the first 24 to 48 hours after the injury. C. Maintain the ankle in a dependent position. D. Exercise hourly by performing rotation exercises of the ankle.
A. Keep an elastic compression bandage on the ankle. Treatment of a sprain consists of resting and elevating the affected part, applying cold, and using a compression bandage. After the acute inflammatory stage (usually 24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises would likely be painful.
Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. A. Knowledge of the anatomy of the nervous system B. Understanding of the tests used to diagnose neurologic disorders C. The ability to interpret the results of diagnostic tests D. The ability to select mediations for the neurologic dysfunction E. Knowledge of nursing interventions related to assessment and diagnostic testing
A. Knowledge of the anatomy of the nervous system B. Understanding of the tests used to diagnose neurologic disorders E. Knowledge of nursing interventions related to assessment and diagnostic testing Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse.
The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting? A. Monitor her weight daily B. Monitor her bowel movements C. Monitor her blood pressure daily D. Assess her radial pulses daily
A. Monitor her weight daily To assess fluid balance at home, the patient should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance
A patient has sustained a long bone fracture and the nurse is preparing the patient's care plan. Which of the following should the nurse include in the care plan? A. Monitor temperature and pulses of the affected extremity. B. Administer corticosteroids as ordered. C. Administer vitamin D and calcium supplements as ordered. D. Perform passive range of motion exercises as tolerated.
A. Monitor temperature and pulses of the affected extremity The nurse should include monitoring for sufficient blood supply by assessing the color, temperature, and pulses of the affected extremity. Weight-bearing exercises are encouraged, but passive ROM exercises have the potential to cause pain and inhibit healing. Corticosteroids, vitamin D, and calcium are not normally administered.
A patient with cardiovascular disease is being treated with amlodipine (Norvasc), a calcium channel blocking agent. The therapeutic effects of calcium channel blockers include which of the following? A. Reducing the heart's workload by decreasing heart rate and myocardial contraction B. Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart C. Preventing platelet aggregation and subsequent thrombosis D. Increasing the efficiency of myocardial oxygen consumption, thus decreasing ischemia and relieving pain
A. Reducing the heart's workload by decreasing heart rate and myocardial contraction Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are administered to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.
The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patient's care? Selected Answers: A. Relieve patient symptoms. B. Improve functional status C. Prevent endocarditis. D. Extend survival. E. Limit physical activity.
A. Relieve patient symptoms. B. Improve functional status D. Extend survival. The overall goals of management of HF are to relieve the patient's symptoms, to improve functional status and quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal. Endocarditis is not a common complication of HF and preventing it is not a major goal of care.
A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? A. Removing excess air and fluid B. Providing positive intrathoracic pressure C. Maintaining positive chest-wall pressure D. Monitoring pleural fluid osmolarity
A. Removing excess air and fluid Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure.
A patient is admitted to the critical care unit (CCU) with a diagnosis of cardiomyopathy. When reviewing the patient's most recent laboratory results, the nurse should prioritize assessment of which of the following? A. Sodium B. AST, ALT, and bilirubin C. BUN D. White blood cell differential
A. Sodium Sodium is the major electrolyte involved with cardiomyopathy. Cardiomyopathy often leads to heart failure which develops, in part, from fluid overload. Fluid overload is often associated with elevated sodium levels. Consequently, sodium levels are followed more closely than other important laboratory values, including BUN, leukocytes, and liver function tests.
An adult patient has tested positive for tuberculosis (TB). While providing patient teaching, what information should the nurse prioritize? A. The importance of adhering closely to the prescribed medication regimen B. The fact that TB is self-limiting, but can take up to 2 years to resolve C. The fact that the disease is a lifelong, chronic condition that will affect ADLs D. The need to work closely with the occupational and physical therapists
A. The importance of adhering closely to the prescribed medication regimen Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.
The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid? A. Washing his face B. Drinking large amounts of fluids C. Using artificial tears D. Exposing his skin to sunlight
A. Washing his face Washing the face should be avoided if possible because this activity can trigger an attack of pain in a patient with trigeminal neuralgia. Using artificial tears would be an appropriate behavior. Exposing the skin to sunlight would not be harmful to this patient. Temperature extremes in beverages should be avoided.
An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? A. "When was the last time you were hospitalized?" B. "Are you exposed to any toxins or chemicals at work?" C. "What medications are you currently taking?" D. "How would you describe your ability to cope with stress?" E. "Does anyone else in your family struggle with headaches?"
B. "Are you exposed to any toxins or chemicals at work?" C. "What medications are you currently taking?" D. "How would you describe your ability to cope with stress?" E. "Does anyone else in your family struggle with headaches?" Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and stress. Hospitalization is an unlikely contributor to headaches.
In preparation for cardiac surgery, a patient was taught about measures to prevent venous thromboembolism. What statement indicates that the patient clearly understood this education? A. "I'll put on those compression stockings if I get pain in my calves." B. "I'll make sure that I don't cross my legs when I'm resting in bed." C. "I'll try to stay in bed for the first few days to allow myself to heal." D. "I'll keep pillows under my knees to help my blood circulate better."
B. "I'll make sure that I don't cross my legs when I'm resting in bed." To prevent venous thromboembolism, patients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge.
A patient returns to the unit after a neck dissection. The surgeon placed a Jackson Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the physician immediately for what? A. 120 mL of serosanguinous drainage B. 60 mL of milky or cloudy drainage C. Presence of small blood clots in the drainage D. Spots of drainage on the dressings surrounding the drain
B. 60 mL of milky or cloudy drainage Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours. Milky drainage is indicative of a chyle fistula, which requires prompt treatment.
The surgical nurse is admitting a patient from postanesthetic recovery following the patient's below-the-knee amputation. The nurse recognizes the patient's high risk for postoperative hemorrhage and should keep which of the following at the bedside? A. A dose of protamine sulfate B. A tourniquet C. A syringe preloaded with vitamin K D. A unit of packed red blood cells, placed on ice
B. A tourniquet Immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the patient's bedside so that, if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. PRBCs cannot be kept at the bedside. Vitamin K and protamine sulfate are antidotes to warfarin and heparin, but are not administered to treat active postsurgical bleeding.
A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the physician to order for the treatment of this disease process? A. Cyclobenzaprine (Flexeril) B. Acyclovir (Zovirax) C. Ampicillin (Prinicpen) D. Cyclosporine (Neoral)
B. Acyclovir (Zovirax) Acyclovir (Zovirax) or ganciclovir (Cytovene), antiviral agents, are the medications of choice in the treatment of HSV. The mode of action is the inhibition of viral DNA replication. To prevent relapse, treatment would continue for up to 3 weeks. Cyclosporine is an immunosuppressant and antirheumatic. Cyclobenzaprine is a centrally acting skeletal muscle relaxant. Ampicillin, an antibiotic, is ineffective against viruses.
A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU? A. Determine if the patient smokes. B. Begin ECG monitoring. C. Auscultate lung fields. D. Obtain information about family history of heart disease.
B. Begin ECG monitoring. The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the patient smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.
The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure? A. Jugular vein distention B. Bibasilar fine crackles C. Right upper quadrant pain D. Dependent edema
B. Bibasilar fine crackles Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
A patient has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The physician's choice of antibiotics would be primarily based on what diagnostic test? A. Echocardiography B. Blood cultures C. Complete blood count D. Cardiac aspiration
B. Blood cultures To help determine the causative organisms and the most effective antibiotic treatment for the patient, blood cultures are taken. A CBC can help establish the degree and stage of infection, but not the causative microorganism. Echocardiography cannot indicate the microorganisms causing the infection. "Cardiac aspiration" is not a diagnostic test.
The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse effects, the nurse should assess for which of the following signs and symptoms? A. Numbness and tingling in the extremities B. Confusion and bradycardia C. Uncontrolled diuresis and tachycardia D. Chest pain and shortness of breath
B. Confusion and bradycardia A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.
A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply. A. Systemic infection B. Deep vein thrombosis C. Compartment syndrome D. Complex regional pain syndrome E. Fat embolism
B. Deep vein thrombosis C. Compartment syndrome E. Fat embolism Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and CRPS are later complications of fractures.
The nurse is auscultating the breath sounds of a patient with pericarditis. What finding is most consistent with this diagnosis? A. Fine crackles B. Friction rub C. Wheezes D. Coarse crackles
B. Friction rub A pericardial friction rub is diagnostic of pericarditis. Crackles are associated with pulmonary edema and fluid accumulation, whereas wheezes signal airway constriction; neither of these occurs with pericarditis.
The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse do first? A. Check for a carotid pulse. B. Gently shake and shout, "Are you OK?" C. Apply supplemental oxygen. D. Give two full breaths.
B. Gently shake and shout, "Are you OK?" Assessing responsiveness is the first step in basic life support. Opening the airway and checking for respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by supplementary oxygen. Circulation is checked by palpating the carotid artery.
A patient asks the nursing assistant for a bedpan. When the patient is finished, the nursing assistant notifies the nurse that the patient has bright red streaking of blood in the stool. What is this most likely a result of? A. Diet high in red meat B. Hemorrhoids C. Use of iron supplements D. Upper GI bleed
B. Hemorrhoids Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool. Hemorrhoids are often a cause of anal bleeding since they occur in the rectum. Blood from an upper GI bleed would be dark rather than frank. Iron supplements make the stool dark, but not bloody and red meat consumption would not cause frank blood.
The nurse is caring for a patient whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer? A. Frequent nosebleeds B. Hoarseness C. Dysphagia D. Dyspnea
B. Hoarseness Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.
A patient visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the patient to perform which of the following? A. Apply a mustard poultice to the forehead. B. Increase fluid intake. C. Apply a cold pack to the affected area. D. Perform postural drainage.
B. Increase fluid intake. For a patient diagnosed with acute sinusitis, the nurse should instruct the patient that hot packs, increasing fluid intake, and elevating the head of the bed can promote drainage. Applying a mustard poultice will not promote sinus drainage. Postural drainage is used to remove bronchial secretions.
The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure? A. Increase in the patient's resting heart rate B. Increase in the size of the artery's lumen C. Decrease in arterial blood flow in relation to venous flow D. Increase in the patient's level of consciousness (LOC)
B. Increase in the size of the artery's lumen PTCA is used to open blocked coronary vessels and resolve ischemia. The procedure may result in beneficial changes to the patient's LOC or heart rate, but these are not the overarching goals of PTCA. Increased arterial flow is the focus of the procedures.
The campus nurse at a university is assessing a 21-year-old student who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the student to tilt her head forward and the nurse applies pressure to the nose, but the student's nose continues to bleed. Which intervention should the nurse next implement? A. Arrange for transfer to the local ED B. Insert a tampon in the affected nare C. Apply ice to the bridge of her nose D. Lay the patient down on a cot
B. Insert a tampon in the affected nare A cotton tampon may be used to try to stop the bleeding. The use of ice on the bridge of the nose has no scientific rationale for care. Laying the client down on the cot could block the client's airway. Hospital admission is necessary only if the bleeding becomes serious.
The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurse's postprocedure care? A. Administering oral suction as needed B. Maintaining the patient's chest tube C. Assisting with pulmonary function testing (PFT) D. Performing chest physiotherapy
B. Maintaining the patient's chest tube Chest tube drainage is required after mediastinotomy. PFT, chest physiotherapy, and oral suctioning would all be contraindicated because of the patient's unstable health status.
An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions? A. Bed rest, albuterol nebulizer treatments, and oxygen B. Morphine sulphate, oxygen, and bed rest C. Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories D. Oxygen and beta-adrenergic blockers
B. Morphine sulphate, oxygen, and bed rest The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine sulphate reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.
A 45-year-old obese man arrives in a clinic with complaints of daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem? A. Laryngeal cancer B. Obstructive sleep apnea C. Adenoiditis D. Chronic tonsillitis
B. Obstructive sleep apnea Obstructive sleep apnea occurs in men, especially those who are older and overweight. Symptoms include excessive daytime sleepiness, insomnia, and snoring. Daytime sleepiness and difficulty going to sleep at night are not indications of tonsillitis or adenoiditis. This patient's symptoms are not suggestive of laryngeal cancer.
A patient is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk? A. Administration of bronchodilators by nebulizer B. Patient's consistent performance of deep breathing and coughing exercises C. Administration of inhaled corticosteroids by metered dose inhaler (MDI) D. Patient's active participation in the cardiac rehabilitation program
B. Patient's consistent performance of deep breathing and coughing exercises Clearance of pulmonary secretions is accomplished by frequent repositioning of the patient, suctioning, and chest physical therapy, as well as educating and encouraging the patient to breathe deeply and cough. Medications are not normally used to achieve this goal. Rehabilitation is important, but will not necessarily aid the mobilization of respiratory secretions.
A nurse is caring for a patient who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the patient and notes the presence of high-pitched adventitious sounds over the patient's trachea on auscultation. The patient's oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurse's most appropriate action? A. Activate the emergency response system. B. Report this finding promptly to the physician and remain with the patient. C. Reposition the patient into a prone or semi-Fowler's position and apply supplementary oxygen by nasal cannula. D. Encourage the patient to perform deep breathing and coughing exercises hourly.
B. Report this finding promptly to the physician and remain with the patient. In the immediate postoperative period, the nurse assesses for stridor (coarse, high-pitched sound on inspiration) by listening frequently over the trachea with a stethoscope. This finding must be reported immediately because it indicates obstruction of the airway. The patient's current status does not warrant activation of the emergency response system, and encouraging deep breathing and repositioning the patient are inadequate responses.
The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply. A. Hypotension B. Syncope C. Unusual fatigue D. Peripheral cyanosis E. Dyspnea
B. Syncope C. Unusual fatigue E. Dyspnea Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS.
A nurse is admitting a patient diagnosed with late-stage gastric cancer. The patient's family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor contributes to the fact that gastric cancer is often detected at a later stage? A. Gastric cancer does not cause signs or symptoms until metastasis has occurred. B. The early symptoms of gastric cancer are usually not alarming or highly unusual. C. Adherence to screening recommendations for gastric cancer is exceptionally low. D. Early symptoms of gastric cancer are usually attributed to constipation.
B. The early symptoms of gastric cancer are usually not alarming or highly unusual. Symptoms of early gastric cancer, such as pain relieved by antacids, resemble those of benign ulcers and are seldom definitive. Symptoms are rarely a cause for alarm or for detailed diagnostic testing. Symptoms precede metastasis, however, and do not include constipation.
A patient who has undergone valve replacement surgery is being prepared for discharge home. Because the patient will be discharged with a prescription for warfarin (Coumadin), the nurse should educate the patient about which of the following? A. The need to learn to sleep in a semi-Fowler's position for the first 6 to 8 weeks to prevent emboli B. The need for regularly scheduled testing of the patient's International Normalized Ratio (INR) C. The need to take enteric-coated ASA on a daily basis D. The need to avoid foods that contain vitamin K
B. The need for regularly scheduled testing of the patient's International Normalized Ratio (INR) Patients who take warfarin (Coumadin) after valve replacement have individualized target INRs; usually between 2 and 3.5 for mitral valve replacement and 1.8 and 2.2 for aortic valve replacement. Natural sources of vitamin K do not normally need to be avoided and ASA is not indicated. Sleeping upright is unnecessary.
The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs? A. The patient's respiratory rate exceeds 30 breaths/min. B. The patient experiences chest pain, palpitations, or dyspnea. C. The patient's oxygen saturation level drops below 96%. D. The patient experiences a noticeable increase in heart rate during activity.
B. The patient experiences chest pain, palpitations, or dyspnea. Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most patients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.
A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? A. The patient will likely require lifelong treatment with anticholinergic medications. B. The patient needs to be assessed for MS. C. The disease is self-limiting and the patient will achieve pain relief over time. D. The patient has a disproportionate risk of developing myasthenia gravis later in life.
B. The patient needs to be assessed for MS. Patients that develop trigeminal neuralgia before age 50 should be evaluated for the coexistent of MS because trigeminal neuralgia occurs in approximately 5% of patients with MS. Treatment does not include anticholinergics and the disease is not self-limiting. Trigeminal neuralgia is not associated with an increased risk of myasthenia gravis.
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patient's closed chest-drainage system. What should the nurse conclude? A. The chest tube is obstructed. B. The system has an air leak. C. The system is functioning normally. D. The patient has a pneumothorax.
B. The system has an air leak. Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding? A. This result indicates muscle injury, but does not specify the source. B. This is an accurate indicator of myocardial injury. C. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. D. Because the patient has a history of unstable angina, this is a poor indicator of myocardial injury.
B. This is an accurate indicator of myocardial injury. Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even with a diagnosis of unstable angina, this is an accurate indicator of myocardial injury.
A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects? A. Nervousness or paresthesia B. Throbbing headache or dizziness C. Tinnitus or diplopia D. Drowsiness or blurred vision
B. Throbbing headache or dizziness Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.
A nurse is creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube? A. Locate the marking made after the initial x-ray confirming placement. B. Use a combination of at least two accepted methods for confirming placement. C. Assess the color and pH of aspirate. D. Auscultate the patient's abdomen after injecting air through the tube.
B. Use a combination of at least two accepted methods for confirming placement. There are a variety of methods to check tube placement. The safest way to confirm placement is to utilize a combination of assessment methods.
A lipid profile has been ordered for a patient who has been experiencing cardiac symptoms. When should a lipid profile be drawn in order to maximize the accuracy of results? A. After a meal high in fat B. Thirty minutes after a normal meal C. After a 12-hour fast D. As close to the end of the day as possible
C. After a 12-hour fast Although cholesterol levels remain relatively constant over 24 hours, the blood specimen for the lipid profile should be obtained after a 12-hour fast.
A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication? A. Disuse syndrome B. Skin breakdown C. Compartment syndrome D. Subcutaneous emphysema
C. Compartment syndrome Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.
A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what? A. Maintain anticoagulation B. Improve oxygenation C. Control ventricular heart rate D. Decrease SA node conduction
C. Control ventricular heart rate Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin.
The nurse is conducting a presurgical interview for a patient with laryngeal cancer. The patient states that he drinks approximately six to eight shots of vodka per day. It is imperative that the nurse inform the surgical team so the patient can be assessed for what? A. Nonadherence to postoperative care B. Depression C. Delirium tremens D. Increased risk for infection
C. Delirium tremens Considering the known risk factors for cancer of the larynx, it is essential to assess the patient's history of alcohol intake. Infection is a risk in the postoperative period, but not an appropriate answer based on the patient's history. Depression and nonadherence are risks in the postoperative phase, but would not be critical short-term assessments.
The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patient's respirations. How should the nurse best respond to this assessment finding? A. Encourage the patient to do deep breathing and coughing exercises. B. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. C. Document that the chest drainage system is operating as it is intended. D. Inform the physician promptly that there is in imminent leak in the drainage system.
C. Document that the chest drainage system is operating as it is intended. Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.
The nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy. The nurse's plan of care should address what characteristic manifestation of this disease? A. Diplopia B. Tinnitus C. Facial paralysis D. Pain at the base of the tongue
C. Facial paralysis Bell's palsy is characterized by facial dysfunction, weakness, and paralysis. It does not result in diplopia, pain at the base of the tongue, or tinnitus.
A nurse is caring for a patient who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the patient to monitor closely for what postprocedure complication? A. Crepitus B. Synovial fluid leakage C. Fever D. Fasciculations
C. Fever Following arthroscopy, the patient and family are informed of complications to watch for, including fever. Synovial fluid leakage is unlikely and crepitus would not develop as a postprocedure complication. Fasciculations are muscle twitches and do not involve joint integrity or function.
A patient's total laryngectomy has created a need for alaryngeal speech which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the patient when teaching him about this process? A. Insertion of a specialized nasogastric tube B. Use of an electronically enhanced artificial pharynx C. Fitting for a voice prosthesis D. Training on how to perform controlled belching
C. Fitting for a voice prosthesis In patients receiving transesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth. Once the puncture is surgically created and has healed, a voice prosthesis (Blom-Singer®) is fitted over the puncture site. A nasogastric tube and belching are not required. An artificial pharynx is not used.
An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what? A. Femoral artery B. Brachial artery C. Greater saphenous vein D. Brachial vein
C. Greater saphenous vein The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.
A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult patient who has been experienced vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis? A. Pleurisy B. Valve dysfunction C. Heart failure D. Cardiomyopathy
C. Heart failure The level of BNP in the blood increases as the ventricular walls expand from increased pressure, making it a helpful diagnostic, monitoring, and prognostic tool in the setting of HF. It is not specific to cardiomyopathy, pleurisy, or valve dysfunction.
The nurse is creating a plan of care for a patient with a cardiomyopathy. What priority goal should underlie most of the assessments and interventions that are selected for this patient? A. Absence of complications B. Adherence to the self-care program C. Improved cardiac output D. Increased activity tolerance
C. Improved cardiac output The priority nursing diagnosis of a patient with cardiomyopathy would include improved or maintained cardiac output. Regardless of the category and cause, cardiomyopathy may lead to severe heart failure, lethal dysrhythmias, and death. The pathophysiology of all cardiomyopathies is a series of progressive events that culminate in impaired cardiac output. Absence of complications, adherence to the self-care program, and increased activity tolerance should be included in the care plan, but they do not have the priority of improved cardiac output.
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A. Restrain the patient to prevent injury. B. Open the patient's jaws to insert an oral airway. C. Loosen the patient's restrictive clothing. D. Place patient in high Fowler's position.
C. Loosen the patient's restrictive clothing. An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.
The ED nurse is caring for a patient with a suspected MI. What drug should the nurse anticipate administering to this patient? A. Warfarin B. Oxycodone C. Morphine D. Acetaminophen
C. Morphine The patient with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta- blocker, and other medications, as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are not typically used.
The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? (Mark all that apply.) A. Need for increased fluid intake B. Need for early resumption of prediagnosis activity C. Need for careful monitoring for cardiac symptoms D. Need for dietary modifications E. Need for carefully regulated exercise
C. Need for careful monitoring for cardiac symptoms D. Need for dietary modifications E. Need for carefully regulated exercise Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and diabetes. There is no need to increase fluid intake and activity should be slowly and deliberately increased
A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the patient best make known his wishes for care as his disease progresses? A. Ensure that witnesses are present when he provides instruction. B. Designate a most responsible physician (MRP) early in the course of the disease. C. Prepare an advance directive. D. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association.
C. Prepare an advance directive. Patients with ALS are encouraged to complete an advance directive or "living will" to preserve their autonomy in decision making. None of the other listed actions constitutes a legally binding statement of end-of-life care.
A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions? A. Withholding stimulants 24 to 48 hours prior to exam B. Instructing the patient to void prior to the MRI C. Removing all metal-containing objects D. Initiating an IV line for administration of contrast
C. Removing all metal-containing objects Patient preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the patient to void is patient preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the patient was having a CT scan with contrast.
A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position? A. Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds. B. Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall. C. Turn the patient to enable assessment of all the patient's lung fields. D. Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray.
C. Turn the patient to enable assessment of all the patient's lung fields. Assessment of the anterior and posterior lung fields is part of the nurse's routine evaluation. If the patient is recumbent, it is essential to turn the patient to assess all lung fields so that dependent areas can be assessed for breath sounds, including the presence of normal breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs can result in missing significant findings. This makes the other given options unacceptable.
The nurse is developing a plan of care for a patient with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this patient? A. Assessing frequently for loss of cognitive function B. Maintaining the patient on bed rest C. Using the incentive spirometer as prescribed D. Providing aids to compensate for loss of vision
C. Using the incentive spirometer as prescribed Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré syndrome does not affect cognitive function or vision.
A patient has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse implement following this procedure? A. Perform passive range of motion exercises. B. Apply heat to the knee. C. Maintain the knee in flexion for up to 30 minutes. D. Wrap the joint in a compression dressing.
D. Wrap the joint in a compression dressing. Interventions to perform following an arthroscopy include wrapping the joint in a compression dressing, extending and elevating the joint, and applying ice or cold packs. Passive ROM exercises, static flexion, and heat are not indicated.
A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test? A. "No metal objects can enter the procedure room." B. "You need to fast for 8 hours prior to the test." C. "There will be a lot of noise during the test." D. "You will need to lie still throughout the procedure."
D. "You will need to lie still throughout the procedure." Preparation for CT scanning includes teaching the patient about the need to lie quietly throughout the procedure. If the patient were having an MRI, metal and noise would be appropriate teaching topics. There is no need to fast prior to a CT scan of the brain.
The home care nurse is assessing the home environment of a patient who will be discharged from the hospital shortly after his laryngectomy. The nurse should inform the patient that he may need to arrange for the installation of which system in his home? A. A radiant heating system B. An air conditioning system C. A water purification system D. A humidification system
D. A humidification system The nurse stresses the importance of humidification at home and instructs the family to obtain and set up a humidification system before the patient returns home. Air-conditioning may be too cool and too drying for the patient. A water purification system or a radiant heating system is not necessary.
The nurse has entered a patient's room and found the patient unresponsive and not breathing. What is the nurse's next appropriate action? A. Palpate the patient's carotid pulse. B. Illuminate the patient's call light. C. Begin performing chest compressions. D. Activate the Emergency Response System (ERS).
D. Activate the Emergency Response System (ERS). After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.
A patient with pericarditis has just been admitted to the CCU. The nurse planning the patient's care should prioritize what nursing diagnosis? A. Anxiety related to pericarditis B. Ineffective breathing pattern related to pericarditis C. Ineffective tissue perfusion related to pericarditis D. Acute pain related to pericarditis
D. Acute pain related to pericarditis The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath the clavicle, in the neck, or in the left trapezius (scapula) region. The pain or discomfort usually remains fairly constant, but it may worsen with deep inspiration and when lying down or turning. Anxiety is highly plausible and should be addressed, but chest pain is a nearly certain accompaniment to the disease. Breathing and tissue perfusion are likely to be at risk, but pain is certain, especially in the early stages of treatment.
A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in her femoral region. What is the nurse's most appropriate action? A. Reposition the patient's leg in a nondependent position. B. Call for assistance and initiate cardiopulmonary resuscitation. C. Promptly remove the femoral sheath. D. Call for help and apply pressure to the access site.
D. Call for help and apply pressure to the access site. The femoral sheath produces pressure on the access site. Pressure will temporarily reduce bleeding and allow for subsequent interventions. Removing the sheath would exacerbate bleeding and repositioning would not halt it. CPR is not indicated unless there is evidence of respiratory or cardiac arrest.
A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action? A. Increase the infusion rate of the patient's IV fluid to prompt an increase in renal function. B. Document the patient's low urine output and monitor closely for the next several hours. C. Contact the dietitian and suggest the need for increased oral fluid intake. D. Contact the patient's physician and suggest assessment of fluid balance and renal function.
D. Contact the patient's physician and suggest assessment of fluid balance and renal function. Nursing management includes accurate measurement of urine output. An output of less than 1 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.
When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena? A. Exercise increases the metabolism of cardiac medications. B. Exercise causes vasoconstriction of the coronary arteries. C. Exercise shunts blood flow from the heart to the mesenteric area. D. Exercise increases the heart's oxygen demands.
D. Exercise increases the heart's oxygen demands. Physical exertion increases the myocardial oxygen demand. If the patient has arteriosclerosis of the coronary arteries, then blood supply is diminished to the myocardium. Exercise does not cause vasoconstriction or interfere with drug metabolism. Exercise does not shunt blood flow away from the heart.
When assessing a patient diagnosed with angina pectoris it is most important for the nurse to gather what information? A. The patient's activities limitations and level of consciousness after the attacks B. The patient's coping strategies surrounding the attacks C. The patient's understanding of the pathology of angina D. The patient's symptoms and the activities that precipitate attack
D. The patient's symptoms and the activities that precipitate attack The nurse must gather information about the patient's symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. The patient's coping, understanding of the disease, and status following attacks are all important to know, but causative factors are a primary focus of the assessment interview.
The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patient's sensorium and LOC. Why is the assessment of the patient's sensorium and LOC important in patients with HF? A. Decreased LOC causes an exacerbation of the signs and symptoms of HF. B. The most significant adverse effect of medications used for HF treatment is altered LOC. C. Patients with HF are susceptible to overstimulation of the sympathetic nervous system. D. HF ultimately affects oxygen transportation to the brain.
D. HF ultimately affects oxygen transportation to the brain As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain. Sympathetic stimulation is not a primary concern in patients with HF, although it is a possibility. HF affects LOC but the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and significant effects are cardiovascular.
The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately? A. Oral lorazepam (Ativan) B. Intravenous phenobarbital (Luminal) C. Oral phenytoin (Dilantin) D. Intravenous diazepam (Valium)
D. Intravenous diazepam (Valium) Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan) given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epileptics.
The nurse is providing care for a patient with high cholesterol and triglyceride values. In teaching the patient about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following? A. Elevated blood lipids, fasting glucose less than 100 B. Absence of detectable total cholesterol levels C. High HDL values and high triglyceride values D. Low LDL values and high HDL values
D. Low LDL values and high HDL values The desired goal for cholesterol readings is for a patient to have low LDL and high HDL values. LDL exerts a harmful effect on the coronary vasculature because the small LDL particles can be easily transported into the vessel lining. In contrast, HDL promotes the use of total cholesterol by transporting LDL to the liver, where it is excreted. Elevated triglycerides are also a major risk factor for cardiovascular disease. A goal is also to keep triglyceride levels less than 150 mg/dL. All individuals possess detectable levels of total cholesterol.
A patient with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the patient may be prescribed what drug? A. Lansoprazole (Prevacid) B. Famotidine (Pepcid) C. Omeprazole (Prilosec) D. Metoclopramide (Reglan)
D. Metoclopramide (Reglan) Metoclopramide (Reglan) is useful in promoting gastric motility. Omeprazole and lansoprozole are proton pump inhibitors that reduce gastric acid secretion. Famotidine (Pepcid) is an H2 receptor antagonist, which has a similar effect.
Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A. Gastroesophageal reflux B. Gastritis C. Acute pancreatitis D. Peritonitis
D. Peritonitis Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Chemical peritonitis develops within a few hours of perforation and is followed by bacterial peritonitis. Gastritis, reflux, and pancreatitis are not acute complications of a perforated ulcer.
A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patient's dorsalis pedis or posterior tibial pulse and the patient's foot is pale. What is the nurse's most appropriate action? A. Reposition the patient with the affected foot dependent. B. Warm the patient's foot and determine whether circulation improves. C. Reassess the patient's neurovascular status in 15 minutes. D. Promptly inform the primary care provider.
D. Promptly inform the primary care provider. Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the patient may be of some benefit, but the care provider should be informed first.
A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient? A. Naratriptan (Amerge) B. Zolmitriptan (Zomig) C. Rizatriptan (Maxalt) D. Sumatriptan succinate (Imitrex)
D. Sumatriptan succinate (Imitrex) Triptans can cause chest pain and are contraindicated in patients with ischemic heart disease. Maxalt, Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches.
A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the resident's pain would be most suggestive of angina as the cause? A. The pain is most severe when the resident moves his upper body. B. The pain is worse when the resident coughs. C. The pain is worse when the resident inhales deeply. D. The pain occurs immediately following physical exertion.
D. The pain occurs immediately following physical exertion. Chest pain associated with angina is often precipitated by physical exertion. The other listed aspects of chest pain are more closely associated with noncardiac etiologies.
A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication? A. Side effects of the medication include renal dysfunction. B. Tegretol is not known to have serious adverse effects. C. The medication should be first taken in the maximum dosage form to be effective. D. The patient should be monitored for bone marrow depression.
D. The patient should be monitored for bone marrow depression. The anticonvulsant agents carbamazepine (Tegretol) and phenytoin (Dilantin) relieve pain in most patients diagnosed with trigeminal neuralgia by reducing the transmission of impulses at certain nerve terminals. Side effects include nausea, dizziness, drowsiness, and aplastic anemia. Carbamazepine should be gradually increased until pain relief is obtained.
