Exam 1 Complex

24. A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Administer atropine per agency dysrhythmia protocol. d. Provide supplemental oxygen via non-rebreather mask.

ANS: B The patients clinical manifestations indicate pulseless electrical activity and the nurse should immediately start CPR. The other actions would not be of benefit to this patient.

31. When preparing to defibrillate a patient. In which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the paddles on the patients chest. e. Check the location of other staff and call out all clear.

ANS: A, C, D, E, B This order will result in rapid defibrillation without endangering hospital staff.

30. When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patients heart rate as ____. A. 50 B. 65 C. 30 D. 25

ANS: A. 50 There are 1500 small blocks in a minute, and the nurse will divide 1500 by 30.

5. A patient with chronic back pain has learned to control the pain with the use of imagery and hypnosis. The patients spouse asks the nurse how these techniques work. Which response by the nurse is best? a. The strategies work by affecting the perception of pain. b. These techniques block the pain pathways of the nerves. c. Both strategies prevent transmission of painful stimuli to the brain. d. The therapies slow the release of chemicals in the spinal cord that cause pain.

ANS: A Cognitive therapies affect the perception of pain by the brain rather than affecting efferent or afferent pathways or influencing the release of chemical transmitters in the dorsal horn.

16. The nurse is caring for a 1-day postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). What action by the nurse is a priority? a. Check the respiratory rate. b. Assess for nausea after eating. c. Inspect the abdomen and auscultate bowel sounds. d. Evaluate the sacral and heel areas for signs of redness

ANS: A The patients respiratory rate is the highest priority of care while using PCA medication because of the possible respiratory depression. The other information may also require intervention but is not as urgent to report as the respiratory rate.

21. Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? a. Oxygen saturation of 88% b. Weight gain of 1 kg (2.2 lb) c. Heart rate of 106 beats/minute d. Urine output of 50 mL over 2 hours

ANS: A A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require nursing actions, but the low oxygen saturation rate requires the most immediate nursing action.

25. Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a. Instruct the patient to call for assistance before getting out of bed. b. Explain the association between various dysrhythmias and syncope. c. Educate the patient about the need to avoid caffeine and other stimulants. d. Tell the patient about the benefits of implantable cardioverter-defibrillators.

ANS: A A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient up. The other actions may be needed if dysrhythmias are found to be the cause of the patients syncope, but are not appropriate for syncope of unknown origin

27. Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias? a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia b. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole c. Turns the synchronizer switch to the on position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block

ANS: A Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more education about treatment of cardiac dysrhythmias. The RN should hold the diltiazem until talking to the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be off when defibrillating.

9. A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about a. anticoagulant therapy. b. permanent pacemakers. c. electrical cardioversion. d. IV adenosine (Adenocard).

ANS: A Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate.

8. After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? a. Increase in the patients heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions

ANS: A Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions.

14. A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further diagnostic testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the students family health history.

ANS: A In an aerobically trained individual, sinus bradycardia is normal. The students normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the familys health history. Dyspnea during an aerobic activity such as soccer is normal.

19. A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurses priority action will be to a. give IV morphine sulfate 4 mg. b. give IV diazepam (Valium) 2.5 mg. c. increase nitroglycerin (Tridil) infusion by 5 mcg/min. d. increase dopamine (Intropin) infusion by 2 mcg/kg/min.

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

18. A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic arthritic joint pain following a traumatic injury complains of nausea and abdominal fullness. Which action should the nurse take initially? a. Administer the ordered antiemetic medication. b. Tell the patient that the nausea will subside in about a week. c. Order the patient a clear liquid diet until the nausea decreases. d. Consult with the health care provider about using a different opioid.

ANS: A Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics usually are prescribed to treat this expected side effect. There is no indication that a different opioid is needed, although if the nausea persists, the health care provider may order a change of opioid. Although tolerance develops and the nausea will subside in about a week, it is not appropriate to allow the patient to continue to be nauseated. A clear liquid diet may decrease the nausea, but the best choice would be to administer the antiemetic medication and allow the patient to eat.

14. Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? a. Monitor blood pressure frequently. b. Encourage patient to ambulate in room. c. Titrate nesiritide slowly before stopping. d. Teach patient about home use of the drug.

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

1. To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patients a. P wave. b. Q wave. c. P-R interval. d. QRS complex.

ANS: A The P wave represents the depolarization of the atria. The P-R interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibers. The QRS represents ventricular depolarization. The Q wave is the first negative deflection following the P wave and should be narrow and short.

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

ANS: A The patient should avoid moving the arm on the ICD insertion site until healing has occurred in order to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient.

20. After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. A patient who is cool and clammy, with new-onset confusion and restlessness b. A patient who has crackles bilaterally in the lung bases and is receiving oxygen. c. A patient who had dizziness after receiving the first dose of captopril (Capoten) d. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62

ANS: A The patient who has wet-cold clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion.

18. A patients cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? a. Perform immediate defibrillation. b. Give epinephrine (Adrenalin) IV. c. Prepare for endotracheal intubation. d. Give ventilations with a bag-valve-mask device.

ANS: A The patients rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, the other actions may be appropriate.

6. During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of feeling too tired to get out of bed. Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to fatigue. b. disturbed body image related to weight gain. c. impaired skin integrity related to ankle edema. d. impaired gas exchange related to dyspnea on exertion.

ANS: A The patients statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems.

14. A patient who uses a fentanyl (Duragesic) patch for chronic abdominal pain caused by ovarian cancer asks the nurse to administer the prescribed hydrocodone (Vicodin) tablets, but the patient is asleep when the nurse returns with the medication. Which action is best for the nurse to take? a. Wake the patient and administer the hydrocodone. b. Wait until the patient wakes up and reassess the pain. c. Suggest the use of nondrug therapies for pain relief instead of additional opioids. d. Consult with the health care provider about changing the fentanyl (Duragesic) dose.

ANS: A Because patients with chronic pain frequently use withdrawal and decreased activity as coping mechanisms for pain, sleep is not an indicator that the patient is pain free. The nurse should wake the patient and administer the hydrocodone.

2. A nurse assesses a postoperative patient 2 days after chest surgery. What findings indicate that the patient requires better pain management (select all that apply)? a. Confusion b. Hypoglycemia c. Poor cough effort d. Shallow breathing e. Elevated temperature

ANS: A, C, D, E Inadequate pain control can decrease tidal volume and cough effort, leading to complications such as pneumonia with increases in temperature. Poor pain control may lead to confusion through a variety of mechanism, including hypoventilation and poor sleep quality. Stressors such as pain cause increased release of corticosteroids that can result in hyperglycemia.

26. Based on the Joint Commission Core Measures for patients with heart failure, which topics should the nurse include in the discharge teaching plan for a patient who has been hospitalized with chronic heart failure (select all that apply)? a. How to take and record daily weight b. Importance of limiting aerobic exercise c. Date and time of follow-up appointment d. Symptoms indicating worsening heart failure e. Actions and side effects of prescribed medications

ANS: A, C, D, E The Joint Commission Core Measures state that patients should be taught about prescribed medications, follow-up appointments, weight monitoring, and actions to take for worsening symptoms. Patients with heart failure are encouraged to begin or continue aerobic exercises such as walking, while self-monitoring to avoid excessive fatigue.

1. Which question asked by the nurse will give the most information about the patients metastatic bone cancer pain? a. How long have you had this pain? b. How would you describe your pain? c. How much medication do you take for the pain? d. How many times a day do you take medication for the pain?

ANS: B Because pain is a multidimensional experience, asking a question that addresses the patients experience with the pain will elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning How would you describe your pain? is the best initial question.

3. Which assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

ANS: B Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

21. A 19-year-old student comes to the student health center at the end of the semester complaining that, My heart is skipping beats. An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? a. Start supplemental O2 at 2 to 3 L/min via nasal cannula. b. Ask the patient about current stress level and caffeine use. c. Ask the patient about any history of coronary artery disease. d. Have the patient taken to the hospital emergency department (ED).

ANS: B In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. It is unlikely that the patient has coronary artery disease, and this should not be the first question the nurse asks. The patient is hemodynamically stable, so there is no indication that the patient needs to be seen in the ED or that oxygen needs to be administered.

12. A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate? a. Because you have diabetes, you would not be a candidate for a heart transplant. b. The choice of a patient for a heart transplant depends on many different factors. c. Your heart failure has not reached the stage in which heart transplants are needed. d. People who have heart transplants are at risk for multiple complications after surgery.

ANS: B Indications for a heart transplant include end-stage heart failure (Stage D), but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Diabetic patients who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patients question.

16. A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? a. I b. II c. V2 d. V6

ANS: B Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic (ECG) changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area.

20. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP) when caring for a patient who is using a fentanyl (Duragesic) patch and a heating pad for treatment of chronic back pain? a. Check the skin under the heating pad. b. Take the respiratory rate every 2 hours. c. Monitor sedation using the sedation assessment scale. d. Ask the patient about whether pain control is effective.

ANS: B Obtaining the respiratory rate is included in UAP education and scope of practice. Assessment for sedation, pain control, and skin integrity requires more education and scope of practice.

15. The following medications are prescribed by the health care provider for a middle-aged patient who uses long-acting morphine (MS Contin) for chronic back pain, but still has ongoing pain. Which medication should the nurse question? a. Morphine (Roxanol) b. Pentazocine (Talwin) c. Celecoxib (Celebrex) d. Dexamethasone (Decadron

ANS: B Opioid agonist-antagonists can precipitate withdrawal if used in a patient who is physically dependent on mu agonist drugs such as morphine. The other medications are appropriate for the patient.

8. A patient with second-degree burns has been receiving hydromorphone through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. What action by the nurse is most appropriate? a. Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b. Consult with the health care provider about using a different treatment protocol to control the patients pain. c. Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d. Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.

ANS: B PCAs are best for controlling acute pain. This patients history indicates chronic pain and a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the problem. Teaching the patient to administer unneeded medication before going to sleep can result in over sedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA.

10. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if the a. patient is restless and agitated. b. blood pressure is 90/54 mm Hg. c. patient complains about feeling anxious. d. cardiac monitor shows a heart rate of 61 beats/minute.

ANS: B Patients taking b-adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects

7. After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? a. Carvedilol will help my heart muscle work harder. b. It is important not to suddenly stop taking the carvedilol. c. I can expect to feel short of breath when taking carvedilol. d. Carvedilol will increase the blood flow to my heart muscle.

ANS: B Patients who have been taking b-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking b-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries.

9. Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetals (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will a. reduce heart palpitations. b. decrease spasm of the coronary arteries. c. increase the force of the heart contractions. d. help prevent plaque from forming in the coronary arteries.

ANS: B Prinzmetals angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and b-adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand.

21. A patient who is using a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first? a. Obtain vital signs. b. Remove the fentanyl patch. c. Notify the health care provider. d. Administer the prescribed PRN naloxone (Narcan)

ANS: B The assessment data indicate a possible overdose of opioid. The first action should be to remove the patch. Naloxone administration in a patient who has been chronically using opioids can precipitate withdrawal and would not be the first action. Notification of the health care provider and continued monitoring are also needed, but the patients data indicate that more rapid action is needed. The respiratory rate alone is an indicator for immediate action before obtaining blood pressure, pulse, and temperature.

13. When titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias.

ANS: B The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and blood pressure (BP) and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

25. After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. Patient who is taking carvedilol (Coreg) and has a heart rate of 58 b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L c. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache d. Patient who is taking captopril (Capoten) and has a frequent nonproductive cough

ANS: B The patients low potassium level increases the risk for digoxin toxicity and potentially fatal dysrhythmias. The nurse should assess the patient for other signs of digoxin toxicity and then notify the health care provider about the potassium level. The other patients also have side effects of their medications, but their symptoms do not indicate potentially life-threatening complications.

19. A patient with terminal cancer related pain and a history of opioid abuse complains of breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? a. Use distraction by talking about things the patient enjoys. b. Administer the prescribed PRN immediate-acting morphine. c. Suggest the use of alternative therapies such as heat or cold. d. Consult with the doctor about increasing the MS Contin dose.

ANS: B The patients pain requires rapid treatment and the nurse should administer the immediate-acting morphine. Increasing the MS Contin dose and use of alternative therapies may also be needed, but the initial action should be to use the prescribed analgesic medications.

5. The nurse notes that a patients cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions

ANS: B Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions (PVCs) are multifocal or that the R-on-T phenomenon is occurring

13. Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the off position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.

ANS: B When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned on for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient

1. The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids in the past. Which nursing actions regarding opioid administration are appropriate at this time (select all that apply)? a. Assess for signs that the patient is becoming addicted to the opioid. b. Monitor for therapeutic and adverse effects of opioid administration. c. Emphasize that the risk of some opioid side effects increases over time. d. Teach the patient about how analgesics improve postoperative activity levels. e. Provide instructions on decreasing opioid doses by the second postoperative day.

ANS: B, D Monitoring for pain relief and teaching the patient about how opioid use will improve postoperative outcomes are appropriate actions when administering opioids for acute pain. Although postoperative patients usually need a decreasing amount of opioids by the second postoperative day, each patients response is individual. Tolerance may occur, but addiction to opioids will not develop in the acute postoperative period. The patient should use the opioids to achieve adequate pain control, and so the nurse should not emphasize the adverse effects.

15. Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patients response to the activity, which assessment data would indicate that the exercise level should be decreased? a. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg. b. Oxygen saturation drops from 99% to 95%. c. Heart rate increases from 66 to 92 beats/minute. d. Respiratory rate goes from 14 to 20 breaths/minute.

ANS: C A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise.

22. The nurse reviews the medication orders for an older patient with arthritis in both hips who is complaining of level 3 (0 to 10 scale) hip pain while ambulating. Which medication should the nurse use as initial therapy? a. Naproxen (Aleve) 200 mg orally b. Oxycodone (Roxicodone) 5 mg orally c. Acetaminophen (Tylenol) 650 mg orally d. Aspirin (acetylsalicylic acid, ASA) 650 mg orally

ANS: C Acetaminophen is the best first-choice medication. The principle of start low, go slow is used to guide therapy when treating older adults because the ability to metabolize medications is decreased and the likelihood of medication interactions is increased. Nonopioid analgesics are used first for mild to moderate pain, although opioids may be used later. Aspirin and the NSAIDs are associated with a high incidence of gastrointestinal bleeding in older patients.

24. A patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Assess the IV insertion site for signs of extravasation. b. Teach the patient the reasons for remaining on bed rest. c. Monitor the patients blood pressure and heart rate every hour. d. Titrate the rate to keep the systolic blood pressure >90 mm Hg.

ANS: C An experienced LPN/LVN would be able to monitor BP and heart rate and would know to report significant changes to the RN. Teaching patients, making adjustments to the drip rate for vasoactive medications, and monitoring for serious complications such as extravasation require RN level education and scope of practice.

13. Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum troponin b. Arterial blood gases c. B-type natriuretic peptide d. 12-lead electrocardiogram

ANS: C B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure. A twelve-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

23. A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patients vital signs including oxygen saturation.

ANS: C Because this patient has dyspnea and chest pain in association with the new rhythm, the nurses initial actions should be to address the patients airway, breathing, and circulation (ABC) by starting with oxygen administration. The other actions also are important and should be implemented rapidly

15. A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. I will be sure to take the medication with food. b. I will need to eat more potassium-rich foods in my diet. c. I will call for help when I need to get up to use the bathroom. d. I will expect to feel more short of breath for the next few days.

ANS: C Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of b-adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

12. Heparin is ordered for a patient with a non ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin? a. Heparin enhances platelet aggregation. b. Heparin decreases coronary artery plaque size. c. Heparin prevents the development of new clots in the coronary arteries. d. Heparin dissolves clots that are blocking blood flow in the coronary arteries.

ANS: C Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

22. A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1 to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days

ANS: C Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patients heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

3. A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/minute. a. 15 to 20 b. 20 to 40 c. 40 to 60 d. 60 to 100

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

2. Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? a. Give the patient a list of low-sodium, low-cholesterol foods that should be included in the diet. b. Emphasize the increased risk for heart problems unless the patient makes the dietary changes. c. Help the patient modify favorite high-fat recipes by using monosaturated oils when possible. d. Inform the patient that a diet containing no saturated fat and minimal salt will be necessary.

ANS: C Lifestyle changes are more likely to be successful when consideration is given to the patients values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although lowsodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

9. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include a. limit dietary sources of potassium. b. take the hydrochlorothiazide before bedtime. c. notify the health care provider if nausea develops. d. skip the digoxin if the pulse is below 60 beats/minute

ANS: C Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.

3. The nurse teaches a student nurse about the action of ibuprofen. Which statement, if made by the student, indicates that teaching was effective? a. The drug decreases pain impulses in the spinal cord. b. The drug decreases sensitivity of the brain to painful stimuli. c. The drug decreases production of pain-sensitizing chemicals. d. The drug decreases the modulating effect of descending nerves

ANS: C Nonsteroidal antiinflammatory drugs (NSAIDs) provide analgesic effects by decreasing the production of pain- sensitizing chemicals such as prostaglandins at the site of injury. Transmission of impulses through the spinal cord, brain sensitivity to pain, and the descending nerve pathways are not affected by NSAIDs.

5. 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 feeling like I was suffocating! The nurse will document this assessment finding as a. orthopnea. b. pulsus alternans. c. paroxysmal nocturnal dyspnea. d. acute bilateral pleural effusion.

ANS: C Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.

10. Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? a. The procedure will prevent or minimize the risk for sudden cardiac death. b. The procedure will use cold therapy to stop the formation of the flutter waves. c. The procedure will use electrical energy to destroy areas of the conduction system. d. The procedure will stimulate the growth of new conduction pathways between the atria.

ANS: C Radiofrequency catheter ablation therapy uses electrical energy to burn or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements regarding the procedure are incorrect.

4. IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops a. ventricular ectopy. b. a dry, hacking cough. c. a systolic BP <90 mm Hg. d. a heart rate <50 beats/minute.

ANS: C Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.

7. The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that a. she will take furosemide (Lasix) every day at bedtime. b. the nitroglycerin patch is applied when any chest pain develops. c. she will call the clinic if her weight goes from 124 to 128 pounds in a week. d. an additional pillow can help her sleep if she is feeling short of breath at night.

ANS: C Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 3 to 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an as needed basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by further elevating the head of the bed.

18. A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurses priority action will be to a. have the patient recall the dietary intake for the last 3 days. b. ask the patient about the use of the prescribed medications. c. assess the patient for clinical manifestations of acute heart failure. d. teach the patient about the importance of restricting dietary sodium.

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

16. During the administration of the thrombolytic 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. increase in blood pressure. c. a decrease in level of consciousness. d. a nonsustained episode of ventricular tachycardia.

ANS: C The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

3. Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%? a. Need to begin an aerobic exercise program several times weekly b. Use of salt substitutes to replace table salt when cooking and at the table c. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors d. Importance of making an annual appointment with the primary care provider

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

10. While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the water pill with the heart pill. When planning for the patients discharge the nurse will facilitate a a. consult with a psychologist. b. transfer to a long-term care facility. c. referral to a home health care agency. d. arrangements for around-the-clock care.

ANS: C The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patients home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as a psychologist consult, long-term care, or around-the-clock home care

5. After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective? a. I can expect some nausea as a side effect of nitroglycerin. b. I should only take the nitroglycerin if I start to have chest pain. c. I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apart. d. Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart.

ANS: C The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved after 3 sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

10. When visiting a hospice patient, the nurse assesses that the patient has a respiratory rate of 11 breaths/minute and complains of severe pain. Which action is best for the nurse to take? a. Inform the patient that increasing the morphine will cause the respiratory drive to fail. b. Tell the patient that additional morphine can be administered when the respirations are 12. c. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief. d. Administer a nonopioid analgesic, such as a nonsteroidal antiinflammatory drug (NSAID), to improve patient pain control.

ANS: C The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic like ibuprofen would not provide adequate analgesia or be absorbed quickly. The rule of double effect provides ethical justification for administering an increased morphine dose to provide effective pain control even though the morphine may further decrease the patients respiratory rate.

28. A patient reports dizziness and shortness of breath for several days. During cardiac monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as a. junctional escape rhythm. b. accelerated idioventricular rhythm. c. third-degree atrioventricular (AV) block. d. sinus rhythm with premature atrial contractions (PACs).

ANS: C The inconsistency between the atrial and ventricular rates and the variable P-R interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent P-R intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves.

1. While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patients bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. jugular vein atherosclerosis. c. increased right atrial pressure. d. incompetent jugular vein valves.

ANS: C The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

29. A patient who is complaining of 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 (ECG) tracing. Which action should the nurse take next? a. Prepare to perform electrical cardioversion. b. Have the patient perform the Valsalva maneuver. c. Obtain the patients vital signs including oxygen saturation. d. Prepare to give a b-blocker medication to slow the heart rate.

ANS: C The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia. Further assessment is needed before determining the treatment. Vagal stimulation or bblockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias, but would not be used for sinus tachycardia.

23. An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? a. 2+ pedal edema b. Heart rate of 56 beats/minute c. Blood pressure (BP) of 88/42 mm Hg d. Complaints of fatigue

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

12. The nurse reviews the medication administration record in order to choose the most appropriate pain medication for a patient with cancer who describes the pain as deep, aching and at a level 8 on a 0 to 10 scale. Which medication should the nurse administer? a. Fentanyl (Duragesic) patch b. Ketorolac (Toradol) tablets c. Hydromorphone (Dilaudid) IV d. Acetaminophen (Tylenol) suppository

ANS: C The patients pain level indicates that a rapidly acting medication such as an IV opioid is needed. The other medications also may be appropriate to use, but will not work as rapidly or as effectively as the IV hydromorphone.

13. The nurse is caring for a patient who has diabetes and complains of chronic burning leg pain even when taking oxycodone (OxyContin) twice daily. When reviewing the orders, which prescribed medication is the best choice for the nurse to administer as an adjuvant to decrease the patients pain? a. Aspirin (Ecotrin) b. Celecoxib (Celebrex) c. Amitriptyline (Elavil) d. Acetaminophen (Tylenol)

ANS: C The patients pain symptoms are consistent with neuropathic pain and the tricyclic antidepressants are effective for treating this type of pain. The other medications are more effective for nociceptive pain.

17. A patient is recovering from a myocardial infarction (MI) and 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 next? a. Assess the feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

ANS: C The patients symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patients symptoms

17. A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? a. Auscultate the abdomen. b. Check the capillary refill. c. Auscultate the breath sounds. d. Assess the level of orientation.

ANS: C This patients severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patients volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

14. A patient with ST-segment elevation in three contiguous 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 thrombolytic therapy? a. Do you have any allergies? b. Do you take aspirin on a daily basis? c. What time did your chest pain begin? d. Can you rate your chest pain using a 0 to 10 scale?

ANS: C Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic therapy.

26. Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit? a. Decide whether a patients heart rate of 116 requires urgent treatment. b. Monitor a patients level of consciousness during synchronized cardioversion. c. Observe cardiac rhythms for multiple patients who have telemetry monitoring. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome.

ANS: C UAP serving as telemetry technicians can monitor cardiac rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice.

9. The nurse assesses that a patient receiving epidural morphine has not voided for over 10 hours. What action should the nurse take initially? a. Monitor for withdrawal symptoms. b. Place an indwelling urinary catheter. c. Ask if the patient feels the need to void. d. Document this allergic reaction in the patients chart

ANS: C Urinary retention is a common side effect of epidural opioids. Assess whether the patient feels the need to void. Since urinary retention is a possible side effect, there is no reason for concern of withdrawal symptoms. Placing an indwelling catheter requires an order from the health care provider. Usually an in and out catheter is performed to empty the bladder if the patient is unable to void because of the risk of infection with an indwelling catheter. Urinary retention does not indicate that this reaction is an allergic reaction.

11. Following an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. digitalis preparations. b. b-adrenergic blockers. c. calcium channel blockers. d. angiotensin-converting enzyme (ACE) inhibitors.

ANS: D ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and b-adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The badrenergic blockers are not used as initial therapy for new onset heart failure.

16. A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? a. Furosemide (Lasix) 60 mg b. Captopril (Capoten) 25 mg c. Digoxin (Lanoxin) 0.125 mg d. Carvedilol (Coreg) 3.125 mg

ANS: D Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other medications are appropriate for the patient with ADHF.

6. Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. I will switch from whole milk to 1% milk. b. I like salmon and I will plan to eat it more often. c. I can have a glass of wine with dinner if I want one. d. I will miss being able to eat peanut butter sandwiches.

ANS: D Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

1. When developing a teaching plan for a 61-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. increased risk of cardiovascular disease as people age. d. elevation of the patients low-density lipoprotein (LDL) level.

ANS: D Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patients LDL level. Decreases in LDL will help reduce the patients risk for developing CAD.

11. Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and heart rate. b. fewer complaints of having cold hands and feet. c. improvement in the strength of the distal pulses. d. the ability to do daily activities without chest pain.

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

15. When analyzing the rhythm of a patients electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) a. isoelectric ST segment. b. P-R interval of 0.18 second. c. Q-T interval of 0.38 second. d. QRS interval of 0.14 second.

ANS: D Because the normal QRS interval is 0.04 to 0.10 seconds, the patients QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The P-R interval and Q-T interval are within normal range, and ST segment should be isoelectric (flat).

2. The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? a. Weight loss of 2 pounds in 24 hours b. Hourly urine output greater than 60 mL c. Reduction in patient complaints of chest pain d. Reduced dyspnea with the head of bed at 30 degrees

ANS: D Because the patients major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred, but are not as specific to evaluating this patients response.

4. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? a. The patient states that the pain wakes me up at night. b. The patient rates the pain at a level 3 to 5 (0 to 10 scale). c. The patient states that the pain has increased in frequency over the last week. d. The patient states that the pain goes away with one sublingual nitroglycerin tablet.

ANS: D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

6. A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to a. notify the health care provider immediately. b. give atropine per agency dysrhythmia protocol. c. prepare the patient for temporary pacemaker insertion. d. document the finding and continue to monitor the patient.

ANS: D First-degree atrioventricular (AV) block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary.

17. A patient who has fibromyalgia tells the nurse, I feel depressed because I ache too much to play golf. The patient says the pain is usually at a level 7 (0 to 10 scale). Which patient goal has the highest priority when the nurse is developing the treatment plan? a. The patient will exhibit fewer signs of depression. b. The patient will say that the aching has decreased. c. The patient will state that pain is at a level 2 of 10. d. The patient will be able to play 1 to 2 rounds of golf.

ANS: D For chronic pain, patients are encouraged to set functional goals such as being able to perform daily activities and hobbies. The patient has identified playing golf as the desired activity, so a pain level of 2 of 10 or a decrease in aching would be less useful in evaluating successful treatment. The nurse should also assess for depression, but the patient has identified the depression as being due to the inability to play golf, so the goal of being able to play 1 or 2 rounds of golf is the most appropriate.

17. Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? a. Blood glucose 243 mg/dL b. Serum chloride 92 mEq/L c. Serum sodium 134 mEq/L d. Serum potassium 2.9 mEq/L

ANS: D Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values also are abnormal, they are not likely to be the etiology of the patients PVCs and do not require immediate correction.

4. A nurse assesses a patient with chronic cancer pain who is receiving imipramine (Tofranil) in addition to long-acting morphine. Which statement, if made by the patient, indicates to the nurse that the patient is receiving adequate pain control? a. Im not anxious at all. b. I sleep 8 hours every night. c. I feel much less depressed since Ive been taking the Tofranil. d. The pain is manageable and I can accomplish my desired activities.

ANS: D Imipramine is being used in this patient to manage chronic pain and improve functional ability. Although the medication is also prescribed for patients with depression, insomnia, and anxiety, the evaluation for this patient is based on improved pain control and activity level.

11. The nurse is completing the medication reconciliation form for a patient admitted with chronic cancer pain. Which medication is of most concern to the nurse? a. Amitriptyline (Elavil) 50 mg at bedtime b. Ibuprofen (Advil) 800 mg 3 times daily c. Oxycodone (OxyContin) 80 mg twice daily d. Meperidine (Demerol) 25 mg every 4 hours

ANS: D Meperidine is contraindicated for chronic pain because it forms a metabolite that is neurotoxic and can cause seizures when used for prolonged periods. The ibuprofen, amitriptyline, and oxycodone are all appropriate medications for long-term pain management.

8. When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. canned and frozen fruits. b. fresh or frozen vegetables. c. eggs and other high-protein foods. d. milk, yogurt, and other milk products.

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

2. A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain suddenly complains of rapid onset pain at a level 9 (0 to 10 scale) and requests something for pain that will work now. How will the nurse document the type of pain reported by this patient? a. Somatic pain b. Referred pain c. Neuropathic pain d. Breakthrough pain

ANS: D Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.

4. The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patients cardiac rhythm as a. atrial flutter. b. sinus tachycardia. c. ventricular fibrillation. d. ventricular tachycardia.

ANS: D The absence of P waves, wide QRS, rate >150 beats/minute, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.

7. A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Perform synchronized cardioversion per agency dysrhythmia protocol. d. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

ANS: D The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.

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

ANS: D The frequent firing of the ICD indicates that the patients ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered.

7. A patient with chronic neck pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask? a. Can you describe the quality of your pain? b. Has there been a change in the pain location? c. How would you rate your pain on a 0 to 10 scale? d. Does the pain keep you from doing things you enjoy?

ANS: D The goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions are also appropriate to ask, but information about patient function is more useful in evaluating effectiveness.

19. A patients cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? a. Place the transcutaneous pacemaker pads on the patient. b. Administer atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Document the patients rhythm and assess the patients response to the rhythm. d. Call the health care provider before giving the next dose of metoprolol (Lopressor).

ANS: D The patient has progressive first-degree atrioventricular (AV) block, and the b-blocker should be held until discussing the medication with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic, and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic.

20. A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next? a. Recheck the heart rhythm and BP in 5 minutes. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads.

ANS: D The patient is experiencing symptomatic bradycardia, and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate, and the diltiazem should be held. The Valsalva maneuver will further decrease the rate.

11. After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states a. I will avoid cooking with a microwave oven or being near one in use. b. It will be 1 month before I can take a bath or return to my usual activities. c. I will notify the airlines when I make a reservation that I have a pacemaker. d. I wont lift the arm on the pacemaker side up very high until I see the doctor.

ANS: D The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.

6. A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action by the nurse is best? a. Provide amitriptyline (Elavil) 10 mg orally. b. Administer lorazepam (Ativan) 1 mg orally. c. Offer ibuprofen (Motrin) 400 to 800 mg orally. d. Give immediate-release morphine 30 mg orally.

ANS: D The severe breakthrough pain indicates that the initial therapy should be a rapidly acting opioid, such as the immediate-release morphine. Lorazepam and amitriptyline may be appropriate to use as adjuvant therapy, but they are not likely to block severe breakthrough pain. Use of antianxiety agents for pain control is inappropriate because this patients anxiety is caused by the pain.

2. The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Calculate the number of small squares between one QRS complex and the next and divide into 1500. d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

ANS: D This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer.

23. Which patient with pain should the nurse assess first? a. Patient with postoperative pain who received morphine sulfate IV 15 minutes ago b. Patient with neuropathic pain who has a dose of hydrocodone (Lortab) scheduled now c. Patient who received hydromorphone (Dilaudid) 1 hour ago and currently has a sedation scale of 2 d. Patient who returned from the postanesthesia care unit 2 hours ago and has a respiratory rate of 10

ANS: D This patients respiratory rate indicates possible respiratory depression. The risk for over sedation is greatest in the first 4 hours after transfer from the post anesthesia care unit. Patients should be reassessed 30 minutes after receiving IV opioids for pain. A scheduled oral mediation does not need to be administered exactly at the scheduled time. A sedation scale of 2 indicates adequate pain control from hydromorphone.

8. A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin

ANS: D Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patients risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.

1. A patient with chronic pain who has been receiving morphine sulfate 20 mg IV over 24 hours is to be discharged home on oral sustained-release morphine (MS Contin), which will be administered twice a day. What dosage of MS Contin will be needed for each dose to obtain an equianalgesic dose for the patient? (Morphine sulfate 10 mg IV is equianalgesic to morphine sulfate 30 mg orally.)

ANS: MS Contin 30 mg/dose Morphine sulfate 20 mg IV over 24 hours will be equianalgesic to MS Contin 60 mg in 24 hours. Since the total dose needs to be divided into two doses, each dose should be 30 mg.