nur 425 cc exam 1

Ms. J is taking atorvastatin. Ms. X is taking gemfibrozil. Which nursing intervention is appropriate for both Mr. J and Ms. X? (select all that apply) Avoid fried foods Monitor LDL, VLDL, HDL Instruct the patient to report muscle pain Stop drug immediately if become pregnant Instruct patient to not drink grapefruit juice Watch for bleeding if patient is taking warfarin also Instruct patient to report abdominal pain, jaundice, or fatigue

Avoid fried foods - gemfibrozil BOTH: Monitor LDL, VLDL, HDL BOTH: Instruct the patient to report muscle pain Stop drug immediately if become pregnant - gemfibrozil Instruct patient to not drink grapefruit juice - statin Watch for bleeding if patient is taking warfarin also - gemfibrozil BOTH: Instruct patient to report abdominal pain, jaundice, or fatigue

An RN is teaching a pt who has multiple sclerosis about a new Rx for baclofen. Which of the following instructions should the RN include in the teaching? a. "Do not take antihistamines with this medication." b. "Take the medication on an empty stomach." c. "Stop taking the medication immediately for a headache." d. "Expect to develop diarrhea initially."

a. "Do not take antihistamines with this medication." The nurse should instruct the client not to take antihistamines while taking baclofen. Antihistamines will intensity the depressant effects of baclofen.

An RN is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure? a. "I can't get rid of these hiccups." b. "I feel dizzy when I stand." c. "My incision site stings." d. "I have a headache."

a. "I can't get rid of these hiccups." Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.

An RN is teaching a pt who has multiple sclerosis and a new Rx for dantrolene. Which of the following statements by the pt indicates an understanding of the teaching? a. "I need to apply a sunscreen when I go outside." b. "I can take an over-the-counter antihistamine for allergies when I'm taking this drug." c. "I should take this medication when my spasms are bad." d. "My muscle strength should improve a lot in 2 to 3 days."

a. "I need to apply a sunscreen when I go outside." This medication can cause photosensitivity; therefore, the client should protect her skin by wearing a hat and using sunscreen while in sunlight.

An RN is teaching a pt who is taking atorvastatin daily. Which of the following statements by the pt indicates an understanding of the teaching? a. "I will avoid drinking grapefruit juice." b. "I should take this medication without food." c. "I should expect my stools to turn clay-colored." d. "It is not necessary to have routine lab tests done."

a. "I will avoid drinking grapefruit juice." Grapefruits and grapefruit juice can reduce metabolism of atorvastatin, which increases the risk for toxicity.

An RN is caring for a pt who is going to have a bone marrow biopsy under conscious sedation. The pt expresses fear about the procedure and asks the RN if the biopsy will hurt. Which of the following responses should the nurse make? a. "The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible." b. "Relax, you'll be asleep for most of the procedure and you won't remember a thing." c. "I will call your doctor and tell him you still have questions about the procedure." d. "I can understand because you must be very worried about what the biopsy will show."

a. "The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible." The client is seeking information. This open-ended therapeutic response gives the client the information that the client needs to cope, reassures the client of the nurse's presence, and encourages further communication.

An RN is teaching the partner of a pt who had an acute MI about the reason blood was drawn from the pt. Which of the following statements should the RN make regarding cardiac enzyme studies? a. "These tests help determine the degree of damage to the heart tissues." b. "Cardiac enzymes will identify the location of the MI." c. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." d. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."

a. "These tests help determine the degree of damage to the heart tissues."

Ms. Q says to the nurse, "I keep hearing everyone call my symptoms, 'unstable angina' what is that? Should I be worried? Which is the best response by the nurse? a. "Unstable angina is an emergency and it is part of the acute coronary syndrome" b. "Unstable angina is a type of myocardial infarction, or a heart attack." c. "Unstable angina means that your heart tissue has died" d. "Unstable angina is also called your 'usual chest pain' "

a. "Unstable angina is an emergency and it is part of the acute coronary syndrome" UA, NSTEMI, SMETI all fall under ACS

An RN is providing teaching to a pt who is 2 days postop following a heart transplant. Which of the following statements should the RN include in the teaching? a. "You might no longer be able to feel chest pain." b. "Your level of activity intolerance will not change." c. "After 6 months, you will no longer need to restrict your sodium intake." d. "You will be able to stop taking immunosuppressants after 12 months."

a. "You might no longer be able to feel chest pain." Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart.

An RN on a tele unit is caring for a pt who has unstable angina and is reporting chest pain with a severity of 6/10. The RN administers 1 SL nitro tablet. After 5 min, the pt states that his chest pain is now a 2/10. Which of the following actions should the nurse take? a. Administer another nitroglycerin tablet. b. Initiate a peripheral IV. c. Call the Rapid Response Team. d. Obtain an ECG.

a. Administer another nitroglycerin tablet. Administration guidelines for sublingual nitroglycerin indicate that it is appropriate to administer another tablet 5 min after the first one if the client is still reporting pain.

An RN is providing teaching to a pt who has stable angina and a new prescription for transdermal nitroglycerin. Which of the following instructions should the RN include? (SATA) a. Apply patch to the hairless area and rotate sites. b. Apply a new patch each morning. c. Remove the patch for 10-12 hours daily. d. Apply the patch to dry skin and cover the area with plastic wrap. e. Apply a new patch at the onset of anginal pain.

a. Apply patch to the hairless area and rotate sites. b. Apply a new patch each morning. c. Remove the patch for 10-12 hours daily.

An RN is in the ED assessing a pt who has bradysrhythmia. Which of the following findings should the RN monitor for? a. Confusion b. Friction rub c. Hypertension d. Dry skin

a. Confusion Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.

An RN is assessing a pt who has dilated cardiomyopathy. Which of the following findings should the RN expect? a. Dyspnea on exertion b. Tracheal deviation c. Pericardial rub d. Weight loss

a. Dyspnea on exertion The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.

Which of the following is a likely sign of pain in a patient who cannot verbally communicate with you? (SELECT ALL THAT APPLY) a. Eyes clenched shut when turning the patient b. Decreased respiratory rate c. Patient resists bending of her elbow when you try to contract her arm d. Axillary temperature: 36.8 e. Heart rate of 120 in a 54 year old male f. Mechanical ventilator compliance

a. Eyes clenched shut when turning the patient c. Patient resists bending of her elbow when you try to contract her arm e. Heart rate of 120 in a 54 year old male

A pt's pacemaker is firing electricity at the appropriate times, but the EKG shows a flat line with no EKG complex after each pacer spike. What pacemaker problem does this describe? a. Failure to capture b. Appropriately functioning pacemaker c. Failure to sense d. Failure to pace

a. Failure to capture

Your ICU client has been on continuous fentanyl and propofol drips for 6 hours after being intubated for respiratory failure. You note the following in your assessment: HR: 124 BP: 149/60 T: 36.8 RR: 29 SaO2: 90% Eyes open, patient appears anxious, ventilator alarming Which action is most appropriate? a. Increase the propofol drip rate b. Decrease the propofol drip rate c. Ask the client to practice slow deep breathing d. Call the provider to request antihypertensive medication

a. Increase the propofol drip rate

An RN is planning a presentation for a group of pts w/ HTN. Which of the following lifestyle modifications should the RN include? (SATA) a. Limited alcohol intake b. Regular exercise program c. Decreased magnesium intake d. Reduced potassium intake e. Tobacco cessation

a. Limited alcohol intake b. Regular exercise program e. Tobacco cessation

An RN is teaching about necessary baseline examinations with a female pt who is to start taking atorvastatin. Which of the following baseline examinations should the RN include in the teaching? a. Liver function tests b. Hearing test c. Papanicolaou test d. Dental examination

a. Liver function tests Atorvastatin can cause liver damage and should not be taken by clients who have a hx of liver disease. Client should undergo baseline liver function before beginning therapy and every 6-12 months thereafter

A client is to receive lidocaine as a spinal anesthetic. Which nursing action is most appropriate? a. Monitor for hypotension and be prepared to lower the HOB if this occurs b. Prepare towels for excess diaphoresis c. Prepare cimetidine as a premedication d. Request that the physician order metoprolol to have available once the lidocaine has been administered

a. Monitor for hypotension and be prepared to lower the HOB if this occurs

An RN on a med/surg unit is caring for a pt who reports pain in jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the RN take? a. Obtain an EKG b. Administer enteric-coated acetaminophen c. Administer ibuprofen d. Maintain O2 sats greater than or equal to 92%

a. Obtain an EKG

Which intervals are traditionally measured to be able to evaluate an electrocardiogram? SATA a. QRS b. PR interval c. TR interval d. PT interval

a. QRS b. PR interval

An RN is caring for a pt who has HF and is experiencing AFib. Which of the following findings should the RN plan to monitor for and report to the provider immediately? a. Slurred speech b. Irregular pulse c. Dependent edema d. Persistent fatigue

a. Slurred speech The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.

Ms. Q is having chest pain while watching a documentary at home. Which statement about Ms. Q is true? a. This is characteristic of unstable angina b. This is characteristic of stable angina c. Ms. Q should not take nitroglycerin d. This chest pain will fade and probably go away shortly

a. This is characteristic of unstable angina unstable is pain at rest stable is predictable and happens on exertion

The horizontal axis of the EKG graph paper measures what concept? a. Time b. Voltage c. Cardiac output d. Blood flow

a. Time

An RN in the ED is caring for a pt who is experiencing S/S of an MI. Which of the following lab tests should the RN expect the provider to prescribe? a. Troponin b. Creatinine kinase (CK) c. Brain natriuretic peptide (BNP) d. C-reactive protein

a. Troponin

An RN in the ED is caring for a pt who reports chest pressure and shortness of breath. Which of the following lab tests should the RN anticipate the provider to prescribe? a. Troponin I b. Lipase c. B-type natriuretic peptide (BNP) d. Aspartate aminotransferase (AST)

a. Troponin I The troponins (I and T) are proteins that only exist in cardiac muscle and enter the bloodstream within a few hours of myocardial injury. They are the most specific indicator of myocardial damage.

An RN is providing discharge teaching to a pt who has HF. The RN should instruct the pt to report which of the following findings immediately to the provider? a. Weight gain of 0.9 kg (2 lb) in 24 hr b. Increase of 10 mm Hg in systolic blood pressure c. Dyspnea with exertion d. Dizziness when rising quickly

a. Weight gain of 0.9 kg (2 lb) in 24 hr When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.

A pt who is about to undergo hip arthroplasty tells the RN she is afraid of not receiving adequate anesthesia during the procedure. Which of the following responses should the RN make? a. "I will call the anesthesiologist right away." b. "Can you tell me more about this concern?" c. "You have nothing to be concerned about. You have a competent anesthesiologist." d. "Let's talk about managing your pain after surgery."

b. "Can you tell me more about this concern?" Fears about anesthesia are fairly common, and often stem from past experiences of the client or others and from the fear of a loss of control. This response will encourage the client to communicate more about her fear so the nurse can intervene effectively.

An RN is teaching a pt who has a new prescription for simvastatin. Which of the following instructions should the RN include? a. "You should expect brown-colored urine." b. "You should avoid grapefruit juice." c. "You should monitor for ringing in the ears." d. "You should take the medication in the morning."

b. "You should avoid grapefruit juice." Grapefruit inhibits drug-metabolizing enzyme of simvastatin

An RN is teaching a pt who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the RN include in the teaching? a. Apply a new transdermal patch once a week b. Apply the transdermal patch in the morning c. Apply the transdermal patch in the same location as the previous patch d. Apply a new transdermal patch when chest pain is experienced

b. Apply the transdermal patch in the morning

An RN is caring for a pt who is 8 hrs postop following a CABG. Which of the following findings should the RN report? a. Mediastinal drainage 100 mL/hr b. Blood pressure 160/80 mm Hg c. Temperature 37.1° C (98.8° F) d. Potassium 4.0 mEq/L

b. Blood pressure 160/80 mm Hg The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.

An RN at a provider's office receives a phone call from a pt who reports nausea and unrelieved chest pain after taking a nitroglycerin tablet 5 mins ago. Which of the following is an appropriate response by the RN? a. Tell client to take an antacid b. Instruct client to call 911 c. Tell client to take another nitroglycerin tablet in 15 mins d. Advise the client to come to office

b. Instruct client to call 911 b/c client is having unstable angina or acute MI

An RN is caring for a pt who is being treated for HF and has a prescription for furosemide. The RN should plan to monitor for which of the following adverse effects of the medication? a. Shortness of breath b. Lightheadedness c. Dry cough d. Metallic taste

b. Lightheadedness Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.

An RN is assessing a pt who has hypercholesterolemia and is receiving simvastatin. Which of the following findings should the RN recognize as a potential adverse effect a. Urinary retention b. Muscle weakness c. Orthostatic hypotension d. Blurred vision

b. Muscle weakness Myopathy is an adverse effect of this medication. Signs of myopathy include muscle aches, tenderness, and muscle weakness.

Ms. Q takes one dose of sublingual nitroglycerin. Which is a correct way for her to take this? a. Chew quickly and swallow b. Place tablet under tongue and let it dissolve there c. Take a second and third dose 2 minutes after if this dose doesn't relieve her pain d. Take no more than 5 doses in 15 minutes

b. Place tablet under tongue and let it dissolve there

An RN is providing discharge teaching to a pt who has a precription for transdermal nitroglycerin patches. Which of the following instructions should the RN include in the teaching? a. Apply the new patch to the same site as the previous patch. b. Place the patch on an area of skin away from skin folds and joints. c. Keep the patch on 24 hr per day. d. Replace the patch at the onset of angina.

b. Place the patch on an area of skin away from skin folds and joints. The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly.

Ms. Q has elevated troponin and myoglobin levels. Therefore, the team concludes that she is having an NSTEMI. Which collaborative intervention is appropriate? a. Administer t-PA stat b. Prepare to send Ms. Q to cardiac cath lab within 90 minutes c. Send Ms. Q to the OR for open heart surgery d. Begin a nitroglycerin drip

b. Prepare to send Ms. Q to cardiac cath lab within 90 minutes appropriate for STEMI and NSTEMI

An RN is caring for a pt who was admitted for treatment of L-sided HF and is receiving intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the RN take first? a. Obtain the client's current weight. b. Review serum electrolyte values. c. Determine the time of the last digoxin dose. d. Check the client's urine output.

b. Review serum electrolyte values. Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.

Which is the correct order of normal electrical activity in the cardiac cycle? a. Bundle branches, Purkinje fibers, SA node, AV node b. SA node, AV node, Bundle branches, Purkinje fibers c. SA node, Purkinje fibers, AV node, Bundle brances d. AV node, SA node, Bundle brances, Purkinje fibers

b. SA node, AV node, Bundle branches, Purkinje fibers

Ms. Q feels no relief after 5 minutes. Her husband calls 911 and the ambulance arrives at her home and brings her to the emergency department. Upon learning that Ms. Q took nitroglycerin, what adverse effects does the nurse assess for? (select all that apply) a. Hypertension b. Tachycardia c. Headache d. Thrush e. Dizziness

b. Tachycardia c. Headache e. Dizziness

An RN is assessing a pt who received IV conscious sedation for a colonoscopy. Which of the following findings indicated that the client is ready for discharge? a. The client is restless. b. The client is cooperative and oriented. c. The client shows a brisk response to stimulus. d. The client shows a sluggish response to stimulus.

b. The client is cooperative and oriented. A client who is cooperative, oriented, and calm will have a Ramsay Sedation score of 2, which indicates the client has recovered adequately to go home with a responsible adult.

An RN is assessing a pt who has L-sided HF. Which of the following S/S should the RN expect to find? a. Increased abdominal girth b. Weak peripheral pulses c. Jugular venous neck distention d. Dependent edema

b. Weak peripheral pulses Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure.

An RN in a provider's clinic is assessing a pt who takes sublingual nitroglycerin for stable angina. The pt reports getting a headache each time he takes the medication. Which of the following statements should the RN make? a. "Take only 1 dose of nitro to reduce the risk of getting a headache." b. "There's nothing that can be done to relieve the headaches that nitro causes." c. " Try taking a mild analgesic to relieve the headache." d. "We will ask the provider to prescribe a different medication for you."

c. " Try taking a mild analgesic to relieve the headache."

An RN is caring for a client who is scheduled for a CABG in 2 hr. Which of the following statements requires further clarification by the RN? a. "My arthritis is really bothering me because I haven't taken my aspirin in a week." b. "My blood pressure shouldn't be high because I took my blood pressure medication this morning." c. "I took my warfarin last night according to my usual schedule." d. "I will check my blood sugar because I took a reduced dose of insulin this morning."

c. "I took my warfarin last night according to my usual schedule." Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.

An RN is teaching a pt who has angina pectoris about starting therapy with SL nitro tabs. The RN should include which of the following instructions regarding how to take the medication? a. "Take this medication after each meal and at bedtime." b. "Take one tablet every 15 min during an acute attack." c. "Take one tablet at the first indication of chest pain." d. "Take this medication with 8 ounces of water."

c. "Take one tablet at the first indication of chest pain."

Which drug is best indicated for a patient with history of a spinal cord injury and suffering from severe muscle spasms? a. Propofol b. Lidocaine c. Baclofen d. Midazolam

c. Baclofen

A patient is mechanically ventilated and receiving continuous fentanyl and propofol infusions per protocol. Propofol is infusing at a max rate of 60mcg/kg/mn. The patient presents with: HR: 65 BP: 85/40 T: 36.8 RR: 30 (patient initiating most breaths on own) This patient appears agitated and the ventilator is alarming. Which is the nurses best action? a. Increase the propofol drip rate b. Decrease the propofol drip rate c. Discuss changing the sedative medication to midazolam with the provider d. Discuss increasing the max possible rate for the propofol drip protocol with the provider

c. Discuss changing the sedative medication to midazolam with the provider The correct answer is #3, this patient is demonstrating one of the most common side effects of propofol: hypotension. Additionally this patient is showing signs of agitation and needing to be further sedated. However, the propofol drip rate is at it's max dose. Not only can this patient not receive more propofol due to having reached that maximum dose, but increasing the dose any further could further lower the patient's blood pressure. The team needs to consider a different sedative medication that does not cause these side effects.

An RN is in the ED is caring for a pt who has a BP of 253/139. The RN recognizes that the pt is in a HTN crisis. Which of the following actions should the nurse take first? a. Initiate seizure precautions. b. Tell the client to report vision changes. c. Elevate the head of the client's bed. d. Start a peripheral IV.

c. Elevate the head of the client's bed. The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.

A client with cerebral palsy is receiving dantrolene for muscle spasms. Which statement demonstrates patient teaching was effective? a. I will probably have a lot of muscle rigidity after taking this b. I will need to increase fluid intake because this drug causes constipation c. If I notice abdominal pain or yellowing of my skin, I should let my provider know d. I can take this drug with alcohol as long as I don't drink too much

c. If I notice abdominal pain or yellowing of my skin, I should let my provider know

An RN is admitting a pt who has a leg ulcer and a history of DM. Which of the following focused assessments should the RN use to help differentiate b/w an arterial ulcer and a venous stasis ulcer? a. Explore the client's family history of peripheral vascular disease. b. Note the presence or absence of pain at the ulcer site. c. Inquire about the presence or absence of claudication. d. Ask if the client has had a recent infection.

c. Inquire about the presence or absence of claudication. Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.

An RN in an ED is assessing a pt who is having a suspected MI. Which of the following S/S should the nurse expect to find for a pt experiencing an acute MI? (SATA) a. Orthopnea b. Headache c. Nausea d. Tachycardia e. Diaphoresis

c. Nausea d. Tachycardia e. Diaphoresis

Your ICU client has been on continuous fentanyl and propofol drips for 10 hours after being intubated for respiratory failure. You note the following in your assessment: HR: 94 BP: 84/50 T: 36.8 RR: 29 SaO2: 89% Eyes open, ventilator alarming, patient attempting to remove arm restraints Which action is most appropriate? a. Increase the propofol drip rate b.Administer a propofol bolus c. Recommend to the physician that propofol is discontinued and midazolam started d. Tighten the arm restraints

c. Recommend to the physician that propofol is discontinued and midazolam started

An RN is caring for a pt who came to the emergency department reporting chest pain. The provider suspects an MI. While waiting for the troponin levels report, the pt asks what this blood test will show. Which of the following explanations should the RN provide the client? a. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues b. Troponin is a lipid whose levels reflect the risk for coronary artery disease. c. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. d. Troponin is a protein that helps transport O2 throughout the body

c. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

An RN is caring for a client who is 1 hr postop following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? a. Serosanguineous drainage on dressing b. Severe pain with coughing c. Urine output of 20 mL/hr d. Increase in temperature from 36.8° C (98.2° F) to 37.5° C (99.5° F)

c. Urine output of 20 mL/hr Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.

A pt who has a history of an MI is prescribed aspirin 325 mg. The RN recognizes that the aspirin is given due to which of the following actions of the medication? a. analgesic b. anti-inflammatory c. antiplatelet aggregate d. antipyretic

c. antiplatelet aggregate reduce risk of a second MI or CVA by inhibiting platelet aggregation and reducing thrombus formation

What is the difference between sinus rhythm and sinus bradycardia? a. different rhythm b. different QRS complex c. different rates d. different p waves

c. different rates

An RN is caring for a pt who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the pt is experiencing an MI? a. check the client's BP b. auscultate heart tones c. perform a 12-lead EKG d. determine if pain radiates to the left arm

c. perform a 12-lead EKG

If the R to R ratios in an EKG are inconsistent, what is true about the EKG strip? a. rate is normal b. rhythm is regular c. rhythm is irregular d. rate is abnormal

c. rhythm is irregular

An RN is providing teaching to a pt who has angina pectoris and a new prescription for nitroglycerin sublingual tablets. Which of the following statements by the pt indicates an understanding of the teaching? a. "I'll dial 911 if I still have pain after taking 3 nitro tabs 5 minutes apart." b. "I'll dial 911 if I still have pain after taking 4 nitro tabs over a 20 minute period." c. "I'll dial 911 when I have pain and then take the nitro tabs" d. "I'll dial 911 if 1 nitro tab does not relieve my pain, and then take up to 2 more tabs 5 minutes apart while waiting."

d. "I'll dial 911 if 1 nitro tab does not relieve my pain, and then take up to 2 more tabs 5 minutes apart while waiting."

An RN is teaching a pt who has angina about SL nitro tabs. Which of the following should the nurse include in the teaching? a. "Place one tablet under your tongue every 5 minutes for 30 minutes to relieve chest pain." b. "Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries." c. "You can store the bottle of tablets in your bathroom medicine cabinet." d. "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart."

d. "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart." Nitroglycerin is a nitrate medication that increases collateral blood flow, redistributes blood flow toward the subendocardium, and dilates the coronary arteries.

Which of the following is considered a lethal dysrhythmia? a. Sinus tachy b. Junctional rhythm c. 1st degree AV block d. 3rd degree AV block

d. 3rd degree AV block

For which patient is continuous sedation most appropriate? a. 22 year old male complaining of chest pain and anxiety b. 93 year old female with end stage leukemia and worsening delirium c. 58 year old male with a confirmed ischemic stroke demonstrating right sided weakness and confusion d. 51 year old female with confirmed rib fractures who has just been intubated

d. 51 year old female with confirmed rib fractures who has just been intubated The correct answer is 4- this patient has just been intubated and thus will be placed on the mechanical ventilator- a very uncomfortable experience that requires a calm patient. The other optionts do not present any key information that indicates a need for sedation. Just because a patient is anxious or has a serious condition such as a stroke, does not mean the patient needs to be sedated. Also, many sedative medications can actually cause or worsen delirium. Regardless of all of these options, we should always evaluate the necessity of sedative medications in any patient- even if traditionally that patient may receive sedation- is it best for THIS patient and his or her entire clinical picture?

An RN in the ED is caring for a pt who had an anterior MI. The pt's hx reveals they are 1 week postop following an open cholecystectomy. The RN should identify that which of the following interventions is contraindicated? a. Administering IV morphine sulfate b. Administering oxygen at 2 L/min via nasal cannula c. Helping the client to the bedside commode d. Assisting with thrombolytic therapy

d. Assisting with thrombolytic therapy The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.

An RN is preparing a pt for coronary angiography. Which of the following findings should the RN report to the provider prior to the procedure? a. Hemoglobin 14.4 g/dL b. History of peripheral arterial disease c. Urine output 200 mL/4 hr d. Previous allergic reaction to iodine

d. Previous allergic reaction to iodine The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to iodine might need a steroid or antihistamine prior to the procedure.

An RN is caring for a pt who is receiving heparin therapy and develops hematuria. Which of the following actions should the RN take if the pts aPTT is 96 seconds? a. Increase the heparin infusion flow rate by 2 mL/hr. b. Continue to monitor the heparin infusion as prescribed. c. Request a prothrombin time (PT). d. Stop the heparin infusion.

d. Stop the heparin infusion. The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.

An RN is providing teaching to a pt who has stable angina and a new prescription for nitroglycerin oral, sustained-release capsules. Which of the following instructions should the RN include? a. Take 1 capsule at the onset of anginal pain b. Stop taking the medication is side effects are troublesome. c. Take the medications with meals. d. Swallow the capsules whole.

d. Swallow the capsules whole.

An RN is caring for a pt who has endocarditis. Which of the following findings should the RN recognize as a potential complication? a. Ventricular depolarization b. Guillain-Barré syndrome c. Myelodysplastic syndrome d. Valvular disease

d. Valvular disease Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.

The nurse has just completed a 12-lead EKG on Ms. Q. He notes that she has ST segment depression in 4 leads. Ms. Q overhears the nurse talking about this and asks, "What does that mean? Am I having a heart attack?" What is the nurse's best response? a. You are not having a heart attack, there is just some temporary damage b. You are not having a heart attack, we just need to manage your pain c. You are having a heart attack, the ST depression shows where the damage is d. We do not know if you are having a heart attack, we need to get blood work to confirm whether or not that is true

d. We do not know if you are having a heart attack, we need to get blood work to confirm whether or not that is true ST depression could be d/t unstable angina or an NSTEMI

You walk into your intubated patient's room with an IV fentanyl drip at 25mcg/hour who presents with the following: Heart rate: 130 BP: 140/90 RR: 29 Which of the following should the nurse do first? a. Ask the patient to describe her pain b. Increase the fentanyl drip rate per protocol c. Call the physician for additional pain medication orders d. Get a music therapy consult e. Look at the patient's facial expression and muscle tension

e. Look at the patient's facial expression and muscle tension The correct answer is 5, look at the patient's facila expression and muscle tension. Remember, tachycardia, tachypnea, and hypertension can be signs of a problem other than pain- we need to further assess the patient. Also, asking the patient to describe her pain while she is intubated will be very frustrating for a patient who cannot speak. There is no need to call the physician for additional orders because we do already have a titratable continuous infusion to treat pain, if that is the problem. Getting a music therapy consult may be helpful, but again, we need to first assess the patient further. If with further assessment, the nurse determines that this patient is in fact demonstrating signs of pain, he or she would refer to the continuous infusion orders and increase the drip rate as indicated.