Nursing of Adults Review C

Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina?

"The pain goes away after a nitroglycerin tablet"

Which actions for a patient at risk for venous thromboembolism could the nurse delegate to unlicensed assistive personnel?

Apply sequential compression devices whenever the patient is in bed.

Which laboratory test result will the nurse review to determine the effects of therapy for a patient being treated for heart failure?

B-type natriuretic peptide (BNP)

What should the nurse measure to determine whether there is a delay in impulse conduction through the patient's ventricles?

QRS complex

An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol. Which assessment finding is most important for the nurse to report to the health care provider?

Blood pressure of 88/42

Which assessment finding in a patient admitted with acute decompensated heart failure requires the most immediate action by the nurse?

02 saturation of 88%

The nurse is assessing a patient with osteoarthritis who uses naproxen for pain management. Which assessment finding should the nurse recognize as likely to require a change in medication?

The patient has dark-colored stools.

Which assessment finding indicate to the nurse that a patient with infective endocarditis has decreased cardiac output?

Urine production of 25 mL/hr.

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department.

"Have you consistently taken your medications?"

The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history focuses on a pertinent risk factor for rheumatic fever?

"Have you had a recent sore throat?"

The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of ineffective endocarditis. Which question by the nurse helps identify a risk factor for IE?

"Have you had dental work done recently?"

Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction. How should the nurse explain the purpose of the heparin to the patient?

"Heparin prevents the development of new clots in the coronary arteries"

A patient with hypertension and gout has a red, painful right great toe. Which action should the nurse include in the plan of care for this patient?

Use a footboard to hold bedding away from the toe.

The nurse started discharge teaching for a patient who is to continue warfarin after hospitalization for venous thromboembolism. Which patient statement indicates a need for additional teaching?

"I should reduce the amount of green, leafy vegetables that I eat"

The nurse is caring for a patient with mitral regurgitation. Referring to the figure below, where should the nurse listen to best hear a murmur typical of mitral regurgitation?

4

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?

48-yr-old with a blood pressure of 160/92 who reports chest pain.

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first?

A patient who has new-onset confusion and restlessness and cool, clammy skin.

A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. The patient reports that joint discomfort prevents favorite activities such as taking a daily walk and sewing. What problem should be the focus of nursing interventions?

Activity intolerance.

The nurse is caring for a patient who is receiving IV furosemide and morphine for the treatment of acute decompensated heart failure with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective?

Reduced dyspnea with the head of bed at 30 degrees.

What findings should indicate to the nurse that colchicine has been effective for a patient with an acute attack of gout?

Reduced joint pain.

A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action should the nurse take?

Assess the nodules for skin breakdown or infection.

When admitting a patient with a non-ST-segment-elevation myocardial infarction to the intensive care unit, which action should the nurse perform first?

Attach the heart monitor.

A patient recovering from a myocardial infarction develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom?

Auscultate for a pericardial friction rub.

Two days after an acute myocardial infarction, a patient reports stabbing chest pain that increases with a deep breath. Which action will the nurse take first?

Auscultate the heart sounds.

The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction 2 days previously. Which information is most important to report to the health care provider?

Bilateral crackles in the mid-lower lobes.

A patient with gout has a new prescription for losartan. What should the nurse plan to monitor?

Blood pressure

Which data indicates to the nurse that the patient with stable angina is experiencing a side effect of metoprolol (Lopressor)?

Blood pressure is 90/54.

A patient diagnosed with hypertension has been prescribed captopril. Which information is most important to teach the patient about this drug?

Change position slowly to help prevent dizziness and falls.

A patient admitted to the coronary care unit with an ST-segment-elevation myocardial infarction is restless and anxious. The blood pressure is 86/40, and heart rate is 132 beats/min. Based on this information, which patient problem is the priority?

Decreased cardiac output

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism requires immediate action by the nurse?

New onset shortness of breath.

Which finding should the nurse expect when assessing a patient who has osteoarthritis of the knee?

Discomfort with joint movement.

A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval is 0.24 seconds. What action should the nurse take?

Document the finding and monitor the patient.

While doing the hospital admission assessment for a thin older adult, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take next?

Document the finding in the patient chart.

A patient who has chest pain is admitted to the emergency department, and all of the following items are prescribed. Which one should the nurse arrange to be completed first?

Electrocardiogram (ECG)

Which result for a patient with systemic lupus erythematosus should the nurse identify as most important to communicate to the health care provider?

Elevated blood urea nitrogen (BUN)

The nurse is developing a teaching plan for a 64-year-old patient with coronary artery disease. Which factor should the nurse focus on during the teaching session?

Elevated low-density lipoprotein (LDL) level.

A patient in the intensive care unit who has acute decompensated heart failure reports severe dyspnea and is anxious, tachypneic, and tachycardia. Several drugs have been prescribed for the patient. Which action should the nurse take first?

Give PRN IV morphine sulfate 4 mg.

A patient on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the agency dysrhythmia protocol should the nurse do first?

Give supplemental O2 at 2 to 3 L/min via nasal cannula.

A patient who has recently had an acute myocardial infarction ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest?

Heart rate increases from 66 to 98.

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

Instruct the patient to call for assistance before getting out of bed.

An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. After the nurse notifies the health care provider, what should the nurse do next?

Keep the patient in bed in the supine position.

An older adult patient who had a mitral valve replacement with a mechanical valve is taking warfarin. What should the nurse include in discharge teaching?

Need for frequent laboratory blood testing.

The nurse notes that a patient who was admitted with heart failure has jugular venous distension (JVD) when lying flat. Which follow-up action should the nurse take?

Observe the neck veins with the patient elevated 45 degrees.

A patient who reports a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic tracing. Which action should the nurse take next?

Obtain the patient's vital signs including 02 saturation.

A patient who has chronic heart failure tells the nurse "I was fine when I went to bed, but I woke up in the middle of the night felling like I was suffocating" How should the nurse document this finding?

Paroxysmal nocturnal dyspnea.

Which patient at the cardiovascular clinic requires the most immediate action by the nurse?

Patient with stable angina whose chest pain has recently increased in frequency.

A patient has pain due to acute pericarditis. What is an appropriate nursing intervention for this problem?

Place the patient in Fowler's position, leaning forward on the table.

A patient with aortic stenosis has acute pain due to decreased coronary blood flow. What would be an appropriate nursing intervention for this patient?

Promote rest to decrease myocardial oxygen demand.

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?

Serum creatinine of 2.8.

Which assessment finding for a patient receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider?

Serum potassium level of 3.0.

The registered nurse is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside. Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse?

Set up the automatic noninvasive BP machine to take readings every 15 minutes.

A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, hot knee. Which assessment finding should the nurse report immediately to the health care provider?

The blood pressure is 86/50.

The nurse is assessing a patient who has admitted to the intensive care unit with a hypertensive emergency. Which finding is most important to report to the health care provider?

The patient cannot move the left arm and leg when asked to do so.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is from an acute myocardial infarction?

The pain has lasted longer than 30 minutes.

During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention?

The patient has developed wheezes throughout the lung fields.

Which assessment information should indicate to the nurse that a patient with an exacerbation of rheumatoid arthritis is experiencing a side effect of prednisone?

The patient's blood glucose is 165.

The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. Which laboratory test result should be most helpful in indicating myocardial damage?

Troponins

When teaching a patient with heart failure on 2000-mg sodium diet, which foods should the nurse recommend limiting?

Yogurt and milk products.