Exam 4 - Perfusion
The nurse in the post anesthesia care unit is caring for a patient recovering from cardiac bypass graft procedure. Arterial blood gas shows the patient to be in respiratory alkalosis. The patient's vital signs are as follows: temperature 32 degrees Celsius, heart rate 65 beats per minute, blood pressure 96/54 mmHg, and respiratory rate of 32 breaths per minute. What action will the nurse do next? a. Apply a bear hugger to the patient b. Titrate the norepinephrine drip c. Administer a morphine sulfate d. Call respiratory therapist to bedside
A
The nurse in the post anesthesia care unit is caring for patient who is recovering from a valve replacement procedure. The patient is on mechanical ventilation and vital signs are stable. Which action is the highest priority for this patient? a. Monitoring chest tube output every 5 minutes b. Ensure patient is effectively breathing c. Checking nasogastric placement d. Color and clarity of urine in catheter bag.
A
The nurse is caring for a 75 year old patient who is being discharged after having a coronary bypass graft surgery. The nurse is explaining the importance of cardiopulmonary fitness while home. What heart rate will the nurse recommend the patient maintain when exercising? a. 145 beats per minute b. 120 beats per minute c. Between 60-100 beats per minute d. Above 100 beats per minute
A
The nurse is caring for patient who is recovering from an open aneurysm repair procedure. Which lab value would the nurse be concerned about? a. Creatinine 2.75 b. BUN 21 c. Hemoglobin 8.5 d. Sodium 132
A
The nurse is educating a patient who is discharging from the hospital after having cardiac surgery one week ago. The nurse recognizes the patient understands medication management when the he/she state: a. "I need to take my Lisinopril daily to reduce my risk of heart failure." b. "I only need to take the metoprolol when I feel my heart skip a beat." c. "I should carry my nitroglycerin pills in my pocket at all times." d. "I should only take the pain pills when my pain is really bad."
A
The nurse understands the importance of educating the community about aneurysm risk because: a. Most people with aneurysms are asymptomatic. b. Aneurysm symptoms can mimic myocardial infarctions. c. Surgery is recommended for aneurysm 4.0-5.4 cm in size. d. Aneurysm can be easily identified with a physical assessment.
A
The nurse understands the pathophysiology of an aortic dissection to be: a. Tear between the inner and middle layer of arterial wall. b. Localized outpouching of the aorta. c. A bleed that is contained by surrounding anatomic structures. d. A bulge on one side of the arterial wall.
A
An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first? a. Obtain the blood pressure. b. Obtain blood for laboratory testing. c. Assess for the presence of an abdominal bruit. d. Determine any family history of kidney disease.
A Because the patient appears to be experiencing aortic dissection, the nurses first action should be to determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.
The nurse is caring for a 78-year-old patient with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider? a. The patient complains of chest pressure when ambulating. b. A loud systolic murmur is heard along the right sternal border. c. A thrill is palpated at the second intercostal space, right sternal border. d. The point of maximum impulse (PMI) is at the left midclavicular line.
A Chest pressure (or pain) occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.
The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? a. The patient has bilateral crackles. b. The patient has bilateral, 4+ peripheral edema. c. The patient has a loud systolic murmur across the precordium. d. The patient has a palpable thrill felt over the left anterior chest.
A Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.
The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Notify the surgeon and anesthesiologist. b. Wrap both the legs in a warming blanket. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.
A Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graft occlusion. These findings should be reported to the physician immediately because this is an emergency situation. Because pulses are marked prior to surgery, the nurse would know whether pulses were present prior to surgery before notifying the health care providers about the absent pulses. Because the patients symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 15 minutes before taking action. A warming blanket will not improve the circulation to the patients legs.
A patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following symptoms to the nurse. Which is most important to communicate to the health care provider? a. Generalized muscle aches and pains b. Dizziness when changing positions quickly c. Nausea when taking the drugs before eating d. Flushing and pruritus after taking the medications
A Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed.
While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. A priority nursing intervention for this patient would be to a. promote rest to decrease myocardial oxygen demand. b. teach the patient about the need for anticoagulant therapy. c. teach the patient to use sublingual nitroglycerin for chest pain. d. raise the head of the bed 60 degrees to decrease venous return.
A Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation.
A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of medications to the nurse. Which medication has the most immediate implications for the patients care? a. Sildenafil (Viagra) b. Furosemide (Lasix) c. Captopril (Capoten) d. Warfarin (Coumadin)
A The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated inpatients who are using sildenafil because of the risk of severe hypotension caused by vasodilation. The other home medications also should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patients treatment.
A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned. Which reply would be most appropriate for the nurse to make? a. What do you think caused your chest pain? b. Where are you planning to go for your vacation? c. Sometimes plans need to change after a heart attack. d. Recovery from a heart attack takes at least a few weeks.
A When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patients plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.
The community nurse is planning education for reducing aneurysm risk. The nurse understands to target which populations (select all that apply): a. Males older than 50 b. Tobacco users c. African Americans d. Obesity e. History of hypertension
A, B, D, E
The nurse is caring for patient who is recovering from an open aneurysm repair procedure. The patient's vital signs are as follows: temperature of 36 degrees Celsius, heart rate of 94 beats per minute, blood pressure of 84/40 mmHg, and respiratory rate of 18 breaths per minute. The patient's central venous pressure is 2 mmHg. What action will the nurse do next? a. Continue to monitor the patient b. Administer 500 mL normal saline bolus c. Start a continuous heparin infusion d. Assess the patient's orientation
B
The nurse on the cardiac unit is caring for patient post cardiac bypass graft procedure with an external pacemaker. The patient asks why the pacer box is present. The nurse explains the pacemaker will a. Correct rapid atrial rhythms such as atrial fibrillation. b. Only be used if the patient develops bradycardia. c. Deliver a shock if it detects ventricular fibrillation. d. Is continuously pacing the heart while it heals.
B
When admitting a patient with a nonST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Obtain the blood pressure. b. Attach the cardiac monitor. c. Assess the peripheral pulses. d. Auscultate the breath sounds.
B Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a cardiac monitor. The other actions also are important and should be accomplished as quickly as possible.
Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Check the abdominal incision for any redness. d. Teach the reason for a prolonged recovery period.
B Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.
The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? a. Begin oral intake. b. Obtain vital signs. c. Assess pedal pulses. d. Start discharge teaching.
B Bleeding is a possible complication after catheterization of the femoral artery, so the nurses first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions are also appropriate but can be done after determining that bleeding is not occurring.
A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about a. low back pain. b. trouble swallowing. c. abdominal tenderness. d. changes in bowel habits.
B Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms will be important to assess for in patients with abdominal aortic aneurysms.
When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Loose, bloody stools c. Hypoactive bowel sounds d. Abdominal pain with palpation
B Loose, bloody stools at this time may indicate intestinal ischemia or infarction, and should be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.
Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision
B The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions.
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.
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.
When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following? a. They will circulate my blood with a machine during the surgery. b. I will have small incisions in my leg where they will remove the vein. c. They will use an artery near my heart to go around the area that is blocked. d. I will need to take an aspirin every day after the surgery to keep the graft open.
B When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.
The nurse is caring for a patient post coronary artery bypass graft who rates his/her pain as an 8 out 10 on the subjective pain scale. The nurse chooses to administer morphine sulfate intravenously as it has which benefits to cardiac patients (select all that apply)? a. Decreasing myocardial oxygen supply b. Decreasing myocardial oxygen consumption c. Reducing contractility of the heart d. Increasing blood pressure e. Decreasing heart rate
B, C, E
A patient is considering options to manage his/her coronary artery disease. The nurse explains a coronary artery bypass graft procedure will: a. Cure the patient's coronary artery disease. b. Replace the leaking valve in the heart. c. Connect grafts to aorta to improve blood flow. d. Place a permeant pacemaker on the heart muscle.
C
The nurse in an intensive care unit is caring for patient who is one day post cardiac bypass graft process. The patient is nervous about the upcoming physical therapy session because of midsternal chest pain he's had since the operation. The patient is connected to a morphine patient controlled analgesic (PCA) pump. What action by the nurse would be most appropriate? a. Let the patient sit out of physical therapy session today b. Notify the provider of the patient's chest pain c. Clarify with the patient how often he is using PCA d. Acknowledge that recovering from heart surgery is difficult
C
The nurse in the Emergency Department is caring for a patient admitted for abrupt anterior chest pain. Which diagnostic test is the nurse to do as the priority a. Chest x-ray b. Complete blood count c. CT scan d. Thoracentesis
C
The nurse is caring for patient in the cardiac unit recovering from a cardiac bypass graft procedure. The patient's spouse comes out to the hallway and expresses concern of the patient's confusion since surgery was 3 days ago. An appropriate response by the nurse would be: a. "Let me call the doctor right away." b. "What specific concerns do you have?" c. "It's common for confusion to occur after this procedure." d. "I'll have the counselor come meet you in the room."
C
The nurse is in the middle of a code blue situation on the intensive care unit. The patient was admitted for an aortic dissection. When completing the initial assessment the nurse noticed pulses paradoxes on the monitor, jugular vein distention, and heard muffled heart sounds. What actions should the code blue team do next? a. Administer 1 mg of epinephrine intravenously b. Administer 200 joules after shouting "all clear" c. Prepare for midsternal needle aspiration d. Stop resuscitation efforts
C
The nurse understands the purpose for a valve repair surgery as: a. The surgeon removes the patient's valve and replacing it with a mechanical one. b. The surgeon grafts a vein over the occluded artery to the aorta to improve blood flow. c. The surgeon sutures the damaged parts of the valve supporting the surrounding muscle. d. The surgeon reconstructs the patient's valve using veins from another area of the body.
C
During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient on the a. use of daily aspirin for anticoagulation. b. correct method for taking the radial pulse. c. need for frequent laboratory blood testing. d. need to avoid any physical activity for 1 month.
C Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. This will require frequent international normalized ratio (INR) testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated.
The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for which patient? a. Patient admitted with a large acute myocardial infarction. b. Patient being discharged after an exacerbation of heart failure. c. Patient who had a mitral valve replacement with a mechanical valve. d. Patient being treated for rheumatic fever after a streptococcal infection.
C Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.
Heparin is ordered for a patient with a nonST-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.
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.
A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient? a. Biologic valves will require immunosuppressive drugs after surgery. b. Mechanical mitral valves need to be replaced sooner than biologic valves. c. Lifelong anticoagulant therapy will be needed after mechanical valve replacement. d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.
C Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system, and immunosuppressive therapy is not needed.
The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the healthcare provider? a. The troponin level is elevated. b. The patient denies ever having a heart attack. c. Bilateral crackles are auscultated in the mid-lower lobes. d. The patient has occasional premature atrial contractions (PACs).
C The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.
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.
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.
Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block
C The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI). Immediate therapy with percutaneous coronary intervention (PCI) or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy, but not as rapidly.
After receiving report, which patient admitted to the emergency department should the nurse assess first? a. 67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse b. 58-year-old who is taking anticoagulants for atrial fibrillation and has black stools c. 50-year-old who is complaining of sudden sharp and worst ever upper back pain d. 39-year-old who has right calf tenderness, redness, and swelling after a long plane ride
C The patients presentation is consistent with dissecting thoracic aneurysm, which will require rapid intervention. The other patients do not need urgent interventions.
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.
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.
When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for a. diastolic murmur. b. peripheral edema. c. shortness of breath on exertion. d. right upper quadrant tenderness.
C The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease but are not indicators of possible hypoxemia.
A patient who has chest pain is admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. Electrocardiogram (ECG) d. Insertion of a peripheral IV
C The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patients care but are not helpful in determining whether the patient is experiencing a myocardial infarction (MI). Peripheral access will be needed but not before the ECG.
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?
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.
The nurse is caring for a patient post coronary artery bypass graft procedure who is on a nitroglycerin intravenous drip. The nurse understands the importance of nitroglycerin with this procedure as: a. Decreasing myocardial oxygen supply. b. Increasing preload. c. Decreasing cardiac output. d. Decreasing afterload.
D
The nurse is caring for a patient with an aortic dissection who will have surgery in the morning and is on an esmolol drip. The patient denies pain, but states some anxiety about tomorrow's surgery. The patient's vital signs are: temperature 35 degrees Celsius, heart rate of 55 beats per minute, blood pressure of 100/60 mmHg, and respiratory rate of 24 breaths per minute. What action will the nurse do next? a. Decreases esmolol rate b. Analyzes heart rhythm c. Level transducer to phlebostatic axis d. Administer alprazolam by mouth
D
The nurse is caring for a patient with an aortic dissection who will have surgery in the morning. The patient's extended family is waiting in the family lounge and asked if they could bring dinner and eat with the patient later today. An appropriate response by the nurse would be: a. "I think he would appreciate some company; that would be fine." b. "I'm sorry he has to have an empty stomach for surgery in the morning." c. "That's a nice gesture, but I would like to ask that you trust me to care for him." d. "How thoughtful, but he requires a calm and quiet environment right now."
D
When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension
D All of the factors contribute to the patients risk, but only hypertension can potentially be modified to decrease the patients risk for further expansion of the aneurysm.
A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 123. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial infarction b. Anxiety related to perceived threat of death c. Stress overload related to acute change in health d. Decreased cardiac output related to cardiogenic shock
D All the nursing diagnoses may be appropriate for this patient, but the hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.
Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n) a. hemoglobin count. b. additional antibiotic. c. decrease in IV infusion rate. d. blood urea nitrogen (BUN) level.
D The decreased urine output suggests decreased renal perfusion, and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patients decreased urinary output.
When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse? a. Heart rate 102 beats/min b. Pedal pulses 1+ bilaterally c. Blood pressure 103/54 mm Hg d. Chest pain level 7 on a 0 to 10 point scale
D The patients chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.
After receiving change-of-shift report about the following four patients, which patient should the nurse assess first? a. 39-year-old with pericarditis who is complaining of sharp, stabbing chest pain b. 56-year-old with variant angina who is to receive a dose of nifedipine (Procardia) c. 65-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge d. 59-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)
D This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patients blood pressure, pulse, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.
While caring for a 23-year-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to a. take antibiotics before any dental appointments. b. limit physical activity to avoid stressing the heart. c. take an aspirin a day to prevent clots from forming on the valve. d. avoid use of over-the-counter (OTC) medications that contain stimulant drugs.
D Use of stimulant medications should be avoided by patients with MVP because these may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic [prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient.
