Adv Med Surg Questions Exam 2
A nurse is completing a medical interview with a client who has elevated cholesterol levels and takes warfarin. The nurse should recognize that which of the following actions by the client can potentiate the effects of warfarin? a)The client follows a low-fat diet to reduce cholesterol b)The client drinks a glass of grapefruit juice daily c)The client sprinkles flax seeds on food 1 hour before taking the anticoagulant d)The client uses garlic to lower cholesterol levels
D. The nurse should recognize that garlic can potentiate the action of the warfarin.
A patient with peripheral artery disease has marked peripheral neuropathy. An appropriate nursing diagnosis for the patient is a.Risk for injury related to decreased sensation. b.Impaired skin integrity related to decreased peripheral circulation. c.Ineffective peripheral tissue perfusion related to decreased arterial blood flow. d.Activity intolerance related to imbalance between oxygen supply and demand.
Answer: A Rationale: Peripheral neuropathy is caused by diminished perfusion to neurons and results in loss of both pressure and deep pain sensations. The patient may not notice lower extremity injuries. Neuropathy increases susceptibility to traumatic injury and results in delay in seeking treatment
Two risk factors for coronary artery disease that increase the workload of the heart and increase myocardial oxygen demand are a.Obesity and smokeless tobacco use. b.Hypertension and cigarette smoking. c.Elevated serum lipids and diabetes mellitus. d.Physical inactivity and elevated homocysteine levels.
Answer: B Rationale: An elevated blood pressure and cigarette smoking (causes vasoconstriction) increase the rate of atherosclerosis. Atherosclerosis increases the workload of the heart and increases myocardial oxygen demand.
A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions? a)Liver b)Beans c)Milk d)Eggs
Answer: B Rationale: Any food that does not contain animal products does not contain cholesterol. Beans are a good source of protein for a client who follows a low-cholesterol diet.
The nurse teaches a patient with peripheral arterial disease. The nurse determines that further teaching is needed if the patient makes which statement? a."I should not use heating pads to warm my feet." b."I should cut back on my walks if it causes pain in my legs." c."I will examine my feet every day for any sores or red areas." d."I can quit smoking if I use nicotine gum and a support group."
Answer: B Rationale: Patients should be taught to exercise to the point of discomfort, stop and rest, and then resume walking until the discomfort recurs. Smoking cessation and proper foot care are also important interventions for patients with peripheral arterial disease.
A patient with severe chronic lung disease is hospitalized with respiratory distress. Which finding would suggest to the nurse that the patient has developed rapid decompensation? a.An SpO2 of 86% b.A blood pH of 7.33 c.Agitation or confusion d.PaCO2 increases from 48 to 55 mm Hg
Answer: C Rationale: It is especially important to monitor specific and nonspecific signs of respiratory failure in patients with chronic lung disease because a small change can cause significant decompensation. Immediately report any change in mental status, such as agitation, combative behavior, confusion, or decreased level of consciousness.
The nurse determines that teaching about implementing dietary changes to decrease the risk of CAD has been effective when the patient says, a."I should not eat any red meat such as beef, pork, or lamb." b."I should have some type of fish at least 3 times a week." c."Most of my fat intake should be from olive oil or the oils in nuts." d."If I reduce the fat in my diet to about 5% of my calories, I will be much healthier."
Answer: C Rationale: Monounsaturated fats are found in natural foods such as nuts and avocados, and are the main component of tea seed oil and olive oil (oleic acid). Canola oil is 57% to 60% monounsaturated fat, olive oil is about 75% monounsaturated fat, and tea seed oil is commonly more than 80% monounsaturated fat. Other sources include macadamia nut oil, grapeseed oil, groundnut oil (peanut oil), sesame oil, corn oil, popcorn, whole grain wheat, cereal, oatmeal, safflower oil, sunflower oil, tea-oil Camellia, and avocado oil. Fat intake should be between 25% and 35% of calories (with most from monounsaturated fats and less from saturated fats); red meats should be reduced or eliminated from the diet. Only fatty fish (such as tuna and salmon) should be included in the diet because fatty fish is high in omega-3 fatty acids.
When assessing a patient with sepsis, which finding would alert the nurse to the onset of acute respiratory distress syndrome (ARDS)? a.SpO2 of 80% b.Use of accessory muscles of respiration c.Fine, scattered crackles on auscultation of the chest d.ABGs of pH 7.33, Paco2 48 mm Hg, and Pao2 80 mm Hg
Answer: C Rationale: The initial presentation of acute respiratory distress syndrome is often subtle. At the time of the initial injury, and for several hours to 1 to 2 days afterward, the patient may not experience respiratory symptoms, or the patient may exhibit only dyspnea, tachypnea, cough, and restlessness. Chest auscultation may be normal or may reveal fine, scattered crackles.
A nurse is teaching a client who takes aspirin daily for coronary artery disease about herbal supplements. The nurse should instruct the client that which of the following herbal supplements may interact adversely with aspirin? a)Cranberry juice b)Aloe vera c)Feverfew d)Flaxseed
Answer: C Rationale: The nurse should instruct the client to avoid taking feverfew with aspirin because it suppresses platelet aggregation and places the client at risk for bleeding when taken with aspirin.
Which clinical manifestations are seen in pts with either Buerger's disease or Raynaud's phenomenon (sata)? a. intermittent fevers b. sensitivity to cold temperatures c. gangrenous ulcers on fingertips d. color changes of fingers and toes e. episodes of superficial vein thrombosis
Correct answers: b, c, d Rationale: Both Buerger's disease and Raynaud's phenomenon have the following clinical manifestations in common: cold sensitivity, ischemic and gangrenous ulcers on fingertips, and color changes of the distal extremity (fingers or toes).
The nurse is caring for a patient who survived a sudden cardiac death. What should the nurse include in the discharge instructions? a."Because you responded well to CPR, you will not need an implanted defibrillator." b."The most common way to prevent another arrest is to take your prescribed drugs." c."Your family members should learn how to perform CPR and practice these skills regularly." d."Since there was no evidence of a heart attack, you do not need to worry about another episode."
Answer: C Rationale: Rapid cardiopulmonary resuscitation, prompt defibrillation (with an automated external defibrillator), and early advanced cardiac life support can produce high long-term survival rates for a witnessed arrest.
A nurse is teaching a client who has a new prescription for aspirin to prevent cardiovascular disease. Which of the following instructions should the nurse include in the teaching? a)Take on an empty stomach b)Expect stools to turn black c)Anticipate the tablets to smell like vinegar d)Monitor for tinnitis
Answer: D Rationale: Tinnitus is a manifestation of salicylism, or aspirin toxicity. Other manifestations include sweating, headache, and dizziness.
The most significant factor in long-term survival of a patient with sudden cardiac death is a.Absence of underlying heart disease. b.Rapid institution of emergency services and procedures. c.Performance of perfect technique in resuscitation procedures. d.Maintenance of 50% of normal cardiac output during resuscitation efforts.
B Rationale: Rapid CPR and prompt defibrillation and early advanced cardiac life support can produce high long term survival rates for a witnessed arrest
When planning care for a pt at risk for pulmonary embolism the nurse prioritizes a. maintaining the patient on bed rest b. using SCD's c. encouraging the pt to cough and deep breathe d. teaching the patient how to use the incentive spirometer
Correct answer: b Rationale: Deep vein thrombosis (DVT) is the primary cause of pulmonary embolism. Preventing DVT with the use of sequential compression devices, early ambulation, and prophylactic use of anticoagulant medications would thus be a priority nursing intervention
It is important for the nurse to assess for which clinical manifestations in a patient who has just undergone a total thyroidectomy (sata) a. confusion b. weight gain c. depressed reflexes d. circumoral numbness e. positive Chvosteks sign
Correct answers: a, d, e Rationale: Inadvertent removal of a portion of or injury to the parathyroid glands during thyroid or neck surgery can result in a lack of parathyroid hormone, leading to hypocalcemia. A positive Chvostek's sign, confusion, and circumoral numbness are manifestations of low serum calcium levels.
The lungs act as an acid-base buffer by: a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.
Correct answer: a Rationale: As a compensatory mechanism, the respiratory system acts on the CO2 + H2O side of the reaction by altering the rate and depth of breathing to "blow off" (through hyperventilation) or "retain" (through hypoventilation) CO2.
Which diagnostic study best differentiates the various types of cardiomyopathy? a. echocardiography b. abg's c. heart catherterization d. endomyocardial biopsy
Correct answer: a Rationale: Echocardiography is the primary diagnostic tool used to differentiate between the different types of cardiomyopathies and other structural heart abnormalities.
The nursing care for a pt with hyponatremia and fluid volume excess includes a. fluid restriction b. administration of hypotonic IV fluids c. adinistration of cation-exchange resin d. placement of an indwelling catheter
Correct answer: a Rationale: In hyponatremia that is caused by water excess, fluid restriction often is all that is needed to treat the problem. The patient would only require an indwelling urinary catheter if the patient is unable to assist with maintaining an accurate output record.
During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is a. osmosis b. diffusion c. active transport d. facilitated diffusion
Correct answer: a Rationale: Osmosis is the movement of water between two compartments separated by a semipermeable membrane. Water moves through the membrane from an area of low solute concentration to an area of high solute concentration.
A key aspect of teaching for the patient on anticoagulant therapy includes which instruction? a. monitor for and report signs of bleeding b. do not take acetaminophen for a headache c. decrease your dietary intake of food containing vitamin K d. arrange to have blood drawn twice a week to check drug effects
Correct answer: a Rationale: Patients taking anticoagulants should be taught to monitor and report any signs of bleeding, which can be a serious complication. Other important patient teaching includes maintenance of a consistent intake of foods containing vitamin K and avoidance of supplements that contain vitamin K. If a patient is taking warfarin, routine coagulation laboratory studies are necessary, although frequency is patient dependent, not necessarily twice a week.
When teaching a patient about the long term consequences of rheumatic fever, the nurse should discuss the possibility of a. valvular disease b. pulmonary hypertension c. superior vena cava syndrome d. hypertrophy of the right ventricle
Correct answer: a Rationale: Rheumatic heart disease is a chronic condition resulting from rheumatic fever that is characterized by scarring and deformity of the heart valves.
After teaching about ways to decrease risk factors for CAD, the nurse recognizes that additional instruction is needed when the patient says a. "I would like to add weight lifting to my exercise program" b. "I can only keep my blood pressure normal with medication" c. "I can change my diet to decrease my intake of saturated fats" d. "I will change my lifestyle to reduce activities that increase my stress"
Correct answer: a Rationale: Risk factors for coronary artery disease include elevated serum levels of lipids, elevated BP, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, certain psychologic states, and elevated homocysteine levels. Weight lifting is not a cardioprotective exercise. An example of health-promoting regular physical activity is brisk walking (3 to 4 miles/hr) for at least 30 minutes five or more times each week.
The most common early clinical manifestations of ARDS that the nurse may observe are a. dyspnea and tachypnea b. cyanosis and apprehension c. hypotension and tachycardia d. respiratory distress and frothy sputum
Correct answer: a Rationale: The initial presentation of acute respiratory distress syndrome (ARDS) is often subtle. At the time of the initial injury and for several hours up to 2 days afterward, the patient may not experience respiratory symptoms, or the patient may exhibit only dyspnea, tachypnea, cough, and restlessness.
Which is a priority nursing intervention for a patient during the acute phase of rheumatic fever? a. administration of antibiotics as ordered b. management of pain with opioid analgesics c. encouragement of fluid intake for hydration d. performance of frequent active range of motion exercises
Correct answer: a Rationale: The primary goal of managing a patient with acute rheumatic fever is to control and eradicate the infecting organism. The nurse should administer antibiotics as ordered to treat the streptococcal infection and teach the patient that completion of the full course of antibiotic therapy is essential for successful treatment.
The nurse is caring for a client who is 2 days post MI. The patient reports that she is experiencing chest pain. She states, "it hurts when I take a deep breath" Which action would be a priority? a. notify physician STAT and obtain 12 lead ECG b. obtain vital signs and auscultate for a pericardial friction rub c. apply high flow O2 by face mask and auscultate breath sounds d. medicate the patient with PRN analgesic and reevaluate in 30 minutes
Correct answer: b Rationale: Acute pericarditis is inflammation of the visceral and/or parietal pericardium. It often occurs 2 to 3 days after an acute myocardial infarction. Chest pain may vary from mild to severe and is aggravated by inspiration, coughing, and movement of the upper body. Sitting in a forward position often relieves the pain. The pain is usually different from pain associated with a myocardial infarction. Assessment of the patient with pericarditis may reveal a friction rub over the pericardium.
A hospitalized patient with a history of chronic stable angina tells the nurse that she is having chest pain. The nurse bases his actions on the knowledge that ischemia a. will always progress to MI b. will be relieved by rest, nitroglycerin, or both c. indicates that irreversible myocardial damage is occurring d. is frequently associated with vomiting and extreme fatigue
Correct answer: b Rationale: Chronic stable angina is chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms. The chest pain is relieved by rest or by rest and medication (e.g., nitroglycerin). The ischemia is transient and does not cause myocardial damage.
A patient is admitted to the hospital with a dx of abdominal aortic aneurysm. Which sx/sx would suggest that his aneurysm has ruptured? a. rapid onset of sob and hemoptysis b. sudden, severe low back pain and bruising along his flank c. gradually increasing substernal chest pain and diaphoresis d. sudden, patchy blue mottling on feet and toes and rest pain
Correct answer: b Rationale: The clinical manifestations of a ruptured abdominal aortic aneurysm include severe back pain, back or flank ecchymosis (Grey Turner's sign), and hypovolemic shock (tachycardia, hypotension, pale clammy skin, decreased urine output, altered level of consciousness, and abdominal tenderness).
The nurse expects the long term tx of a patient with hyperphosphatemia secondary to renal failure will include a. fluid restriction b. calcium supplements c. magnesium supplements d. increased intake of dietary fiber
Correct answer: b Rationale: The major conditions that can lead to hyperphosphatemia are acute kidney injury and chronic kidney disease that alter the ability of the kidneys to excrete phosphate. For the patient with renal failure, long-term measures to reduce serum phosphate levels include phosphate-binding agents or gels, such as calcium carbonate, fluid replacement therapy, and dietary phosphate restrictions.
The patient at highest risk for VTE a. 62yo man with spider veins who is having arthorscopic knee surgery b. a 32yo woman who smokes, takes oral contraceptives, and is planning a trip to Europe c. a 26yo woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor d. an active 72 yo man at home rerecovering from transurethral resection of the prostate for beign prostatic hyperplasia
Correct answer: b Rationale: Three important factors (called Virchow's triad) in the etiology of venous thrombosis are (1) venous stasis, (2) damage of the endothelium (inner lining of the vein), and (3) hypercoagulability of the blood. Patients at risk for venous thrombosis usually have predisposing conditions for these three disorders (see Table 37-8). The 32-year-old woman has the highest risk: long trips without adequate exercise (venous stasis), tobacco use, and use of oral contraceptives. Note: The likelihood of hypercoagulability of blood is increased in women older than 35 years who use tobacco.
The typical fluid replacement for the patient with a fluid volume deficit is a. dextran b. 0.45% saline c. lactated Ringers d. 5% dextrose in 0.45% saline
Correct answer: c Rationale: Administration of an isotonic solution expands only the extracellular fluid (ECF). There is no net loss or gain from the intracellular fluid (ICF). An isotonic solution is the ideal fluid replacement for a patient with an ECF volume deficit. Examples of isotonic solutions include lactated Ringer's solution and 0.9% NaCl.
The nurse is caring for a patient with chronic constrictive pericarditis. Which assessment finding reflects a more serious complication of this condition? a. fatigue b. peripheral edema c. jugular venous distention d. thickened pericardium on echocardiography
Correct answer: c Rationale: Cardiac tamponade is a serious complication of pericarditis. As the compression of the heart increases, decreased left atrial filling results in decreased cardiac output. Neck veins usually are markedly distended as a result of jugular venous pressure elevation related to compression of the right side of the heart. Heart sounds become muffled secondary to sound distortion by the fluid causing compression of the heart.
which pt is at greatest risk for developing hypermagnesemia a. 83yo man with lung cancer and hypertension b. 65yo woman with hypertension and taking beta-adrenergic blockers c. 42yo woman with systemic lupus erythematosus and renal failure d. 50yo man with bph and a uti
Correct answer: c Rationale: Causes of hypermagnesemia include renal failure (especially if the patient is given magnesium products), excessive administration of magnesium for treatment of eclampsia, and adrenal insufficiency.
maintenance of fluid balance in the patient with ARDS involves a. hydration using colloids b. administration of surfactant c. fluid restriction and diuretics as necessary d. keeping the hgb at levels above 9g/dL
Correct answer: c Rationale: In a patient with ARDS, management of fluid balance includes limiting pulmonary edema by monitoring stroke volume variation or maintaining the pulmonary artery wedge pressure as low as possible without impairing cardiac output. Patients are often placed on fluid restriction, and diuretics are used as necessary.
The most common finding in individuals at risk for sudden cardiac death is a. aortic valve disease b. mtiral valve disease c. left ventricular dysfunction d. atherosclerosis heart disease
Correct answer: c Rationale: Left ventricular dysfunction (ejection fraction less than 30%) and ventricular dysrhythmias after myocardial infarction are the strongest predictors of sudden cardiac death (SCD).
The nurse should alert for which manifestation in a pt receiving a loop diuretic? a. restlessness and agitation b. paresthesias and irritability c. weak, irregular pulse and poor muscle tone d. increased blood pressure and muscle spasms
Correct answer: c Rationale: Loop diuretics may result in renal loss of potassium and hypokalemia. Clinical manifestations of hypokalemia include fatigue, muscle weakness, leg cramps, nausea, vomiting, paralytic ileus, paresthesias, decreased reflexes, weak, irregular pulse, polyuria, hyperglycemia, and ECG changes.
The nurse is caring for a patient newly admitted with heart failure secondary to dilated caridiomyopathy. Which intervention would be a priority? a. encourage caregivers to learn CPR b. consider a consultation with hospice for palliative care c. monitor pts response to a prescribed medication d. arrange for the patient to enter a cardiac rehab program
Correct answer: c Rationale: Observing for signs and symptoms of worsening heart failure, dysrhythmias, and embolus formation in patients with dilated cardiomyopathy is essential, as is monitoring drug responsiveness. The goal of therapy is to keep the patient at an optimal level of functioning and out of the hospital. The priority intervention is to manage the acute symptoms with medications.
A patient is recovering from an uncomplicated MI. Which rehab guideline is a priority to include in the teaching plan? a. refrain from sexual activity for a min. of 3 weeks b. plan a diet program that aims for a 1-2 lb wt loss per week c. begin an exercise program that aims for at leave 5 30 minute sessions per week d. consider the use of erectile agents and prophylactic NTG before engaging in sexual activity
Correct answer: c Rationale: Physical activity should be regular, rhythmic, and repetitive, with the use of large muscles to build up endurance (e.g., walking, cycling, swimming, rowing). Physical activity sessions should be at least 30 minutes long. Instruct the patient to begin slowly at personal tolerance (perhaps only 5 to 10 minutes) and build up to 30 minutes.
What are the priority nursing interventions after and abd aortic aneurysm repair? a. assessment of cranial nerves and mental status b. administration of IV heparin and monitoring PT c. administration of IV fluids and monitoring of kidney function d. elevation of legs and application of graduated compression stocking
Correct answer: c Rationale: Postoperative priorities include administration of IV fluids and maintenance of renal perfusion. An adequate blood pressure is important for maintaining graft patency, and administration of IV fluids and blood components (as indicated) is essential for adequate blood flow. The nurse should evaluate renal function by measuring hourly urine output and monitoring daily blood urea nitrogen (BUN) and serum creatinine levels. Irreversible renal failure may occur after aortic surgery, particularly in individuals at high risk.
Rest pain is a manifestation of PAD that occurs due to a chronic a. vasospasm of small cutaneous arteries in the feet b. increase in retrograde venous blood flood in the legs c. decrease in arterial blood flow to the nerves of the feet d. constriction in arterial blood flow to the leg muscles during exercise
Correct answer: c Rationale: Rest pain most often occurs in the forefoot or toes and is aggravated by limb elevation. Rest pain occurs when blood flow is insufficient to meet basic metabolic requirements of the distal tissues. Rest pain occurs more often at night because cardiac output tends to drop during sleep and the limbs are at the level of the heart. Patients often try to achieve partial pain relief by dangling the leg over the side of the bed or sleeping in a chair to allow gravity to maximize blood flow.
A 50 y/o woman weighs 95kg, has a hx of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized plan of care for her, the nurse determines that the most important risk factors for PAD that must be modified are a. weight and diet b. activity level and salt intake c. tobacco use and high blood pressure d. sedentary lifestyle and exercise training
Correct answer: c Rationale: Significant risk factors for peripheral artery disease include tobacco use, hyperlipidemia, elevated levels of high-sensitivity C-reactive protein, diabetes mellitus, and uncontrolled hypertension; the most important is tobacco use. Other risk factors include family history, hypertriglyceridemia, hyperuricemia, increasing age, obesity, sedentary lifestyle, and stress.
The first priority of interprofessional care of a patient with a suspected acute aortic dissection is to a. reduce anxiety b. monitor for chest pain c. control blood pressure d. increase myocardial contractility
Correct answer: c Rationale: The initial goals of therapy for acute aortic dissection without complications are blood pressure (BP) control and pain management. BP control reduces stress on the aortic wall by reducing systolic BP and myocardial contractility.
a patient with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. The nurse's initial action should be to a. elevate the leg to promote venous return b. start anticoagulation therapy with IV heparin c. notify HCP of the change in peripheral perfusion d. place the bed in reverse trendelenburg to promote perfusion
Correct answer: c Rationale: The patient has potentially developed acute arterial ischemia (sudden interruption in the arterial blood supply to the extremity), caused by an embolism from a cardiac thrombus that occurred as a complication of infective endocarditis. Clinical manifestations of acute arterial ischemia include any or all of the six Ps : pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia. Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the HCP should be notified immediately.
Which intervention is most likely to prevent or limit barotrauma in the pt with ARDS who is mechanically ventilated? a. decreasing PEEP b. increasing tidal volume c. use of permissive hypercapnia d. use of positive pressure ventilation
Correct answer: c Rationale: To avoid barotrauma and minimize risk associated with elevated plateau and peak inspiratory pressures, many patient with ARDS are ventilated with smaller tidal volumes and varying amounts of positive end-expiratory pressure (PEEP) to minimize O2 requirements and intrathoracic pressures. One result of this protocol is an elevation in partial pressure of CO2 in arterial blood (PaCO2), called permissive hypercapnia because the PaCO2 is allowed to rise above normal limits.
Which clinical finding would most likely indicate decreased cardiac output in a pt with aortic valve regurgitation? a. reduction in peripheral edema and weight b. carotid venous distention and new onset afib c. significant pulsus paradoxus and diminished peripheral pulses d. SOB on minimal exertion and a diastolic murmur
Correct answer: d Rationale: Clinical manifestations of aortic regurgitation (AR) that indicate decreased cardiac output include severe dyspnea, chest pain, and hypotension. Other manifestations of chronic AR include water-hammer pulse (i.e., a strong, quick beat that collapses immediately), soft or absent S1, presence of S3 or S4, and soft, high-pitched diastolic murmur. A low-pitched diastolic murmur may be heard in severe AR. Early manifestations may include exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.
in planning care and pt teaching for the pt with venous leg ulcers, the nurse recognizes that the most important intervention in healing and control of this condition is a. discussing activity guidelines b. using moist environment dressings c. taking horse chestnut seed extract daily d. applying graduated compression stockings
Correct answer: d Rationale: Compression is essential for treating chronic venous insufficiency (CVI), healing venous ulcers, and preventing ulcer recurrence. Use of custom-fitted graduated compression stockings is one option for compression therapy.
Priority nursing management for a patient with myocarditis includes interventions related to a. meticulous skin care b. antibiotic prophylaxis c. tight glycemic control d. oxygenation and ventilation
Correct answer: d Rationale: General supportive measures for management of myocarditis include interventions to improve ventilation and oxygenation (oxygen therapy, bed rest, and restricted activity).
A patient is diagnosed with mitral stenosis and new onset afib. Which interventions could the nurse delegate to the UAP (SATA) a. obtain and record daily weight b. determine apical-radial pulse rate c. observe for overt signs of bleeding d. obtain and record vital signs, including pulse ox e. teach patient how to purchase a medic alert device
Correct answers: a, c, d Rationale: The nurse may delegate routine procedures such as measuring weights and vital signs. The nurse may give specific directions to the unlicensed assistive personnel (UAP) to observe and report obvious signs of bleeding. The nurse cannot delegate teaching, assessment, or activities that require clinical judgment. Obtaining an apical-radial pulse rate is an assessment.
During the postop care of a 76 year old pt, the nurse monitors the pts intake and output carefully knowing that the pt is at risk for fluid and electrolyte imbalance primarily because a. older adults have impaired thirst mechanism and need reminding to drink fluids b. water accounts for a greater percentage of body weight in the older adult than in younger adults c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults
Correct answer: d Rationale: In the older adult, body water content averages 45% to 50% of body weight; therefore small losses can lead to a greater risk of fluid-related problems.
The nurse in unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to a. apply warm moist compress to the insertion site b. attempt to force 10 mL of normal saline into the device c. place the patient on the left side with head down position d. instruct the patient to change positions, raise arms, and cough
Correct answer: d Rationale: Interventions for catheter occlusion include instructing the patient to change position, raise an arm, and cough; assessing for and alleviating clamping or kinking of the tube; flushing the catheter with normal saline through a 10-mL syringe (do not force flush); using fluoroscopy to determine cause and site of occlusion; and instilling anticoagulant or thrombolytic agents.
The recommended treatment for an initial VTE in an otherwise healthy person with no significant co-morbidities would include a. IV argatroban (Acova) as an inpatient b. IV unfractionated heparin as an inpatient c. subcutaneous unfractionated heparin as an outpatient d. subcutaneous low-molecular weight heparin as an outpatient
Correct answer: d Rationale: Patients with confirmed VTE should receive initial treatment with low-molecular-weight heparin (LMWH), unfractionated heparin (UH), fondaparinux, or rivaroxaban, followed by warfarin for 3 months to maintain the international normalized ratio (INR) between 2.0 and 3.0 for 24 hours. Patients with multiple comorbid conditions, complex medical issues, or a very large VTE usually are hospitalized for treatment and typically receive intravenous UH. LMWH only for 3 months is another option for patients with acute VTE. Depending on the clinical presentation, patients often can be managed safely and effectively as outpatients.
A pt has the following arterial blood gas result: pH 7.52, PaCO2 30mmHg, HCO3 24mEq/L. The nurse determines these results indicate a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis
Correct answer: d Rationale: Respiratory alkalosis (carbonic acid deficit) occurs with hyperventilation. The primary cause of respiratory alkalosis is hypoxemia from acute pulmonary disorders. Anxiety, central nervous system (CNS) disorders, and mechanical overventilation also increase ventilation rate and decrease the partial pressure of arterial carbon dioxide (PaCO2). This leads to a decrease in carbonic acid level and to alkalosis.
The o2 delivery system chosen for the patient in acute respiratory failure should a. always be a low flow device, such as a nasal cannula or face mask b. administer continuous positive airway pressure ventilation to prevent CO2 narcosis c. correct the PaO2 to a normal level as quickly as possible using mechanical ventilation d. maintain the PaO2 at greater than or equal to 60 mmHg at the lowest O2 concentration possible
Correct answer: d Rationale: The selected O2 delivery system must maintain partial pressure of O2 in arterial blood (PaO2) at 55 to 60 mm Hg or higher and arterial O2 saturation (SaO2) at 90% or higher at the lowest O2 concentration possible.
Assessment of an IV cocaine user with infective endocarditis should focus on which signs and symptoms (select all that apply) a. Retinal hemorrhages b. splinter hemorrhages c. presence of Osler's nodes d. Painless nodules over bony prominences e. painless erythematous macules on the palms and soles
Correct answers: a, b, c, e Rationale: Clinical manifestations of infective endocarditis may include hemorrhagic retinal lesions (Roth's spots), splinter hemorrhages (black, longitudinal streaks) that may occur in the nail beds, Osler's nodes (painful, tender, red or purple, pea-size lesions) on the fingertips or toes, and Janeway's lesions (flat, painless, small, red spots) seen on the fingertips, palms, soles of feet, and toes.
A patient is admitted with myocarditis. While performing the initial assessment, the nurse may find which clinical sx/sx? (SATA) a. angina b. pleuritic chest pain c. splinter hemorrhages d. pericardial friction rub e. presence of osler's nodes
Correct answers: a, b, d Rationale: Clinical manifestations of myocarditis may include early systemic manifestations (i.e., fever, fatigue, malaise, myalgias, pharyngitis, dyspnea, lymphadenopathy, and nausea and vomiting), early cardiac manifestations (e.g., pleuritic chest pain with a pericardial friction rub and effusion), and late cardiac signs (e.g., S3 heart sound, crackles, jugular venous distention [JVD], syncope, peripheral edema, and angina).
which sx/sx differentiate hypoxemic respiratory failure from hypercapnic respiratory failure? (sata) a. cyanosis b. tachypnea c. morning headache d. paradoxic breathing e. use of pursed lip breathing
Correct answers: a, b, d Rationale: Clinical manifestations that occur with hypoxemic respiratory failure include cyanosis, tachypnea, and paradoxic chest or abdominal wall movement with the respiratory cycle. Clinical manifestations of hypercapnic respiratory failure include morning headache, pursed-lip breathing, and decreased or increased respiratory rate with shallow breathing.
An older adult woman was admitted to the medical unit with GI bleeding and fluid volume deficit. Clinical manifestations of this problem are (sata) a. weight loss b. dry oral mucosa c. full bounding pulse d. engorged neck veins e. decreased central venous pressure
Correct answers: a, b, e Rationale: Body weight loss, especially sudden change, is an excellent indicator of overall fluid volume loss. Other clinical manifestations of fluid volume deficit include dry mucous membranes and a decreased central venous pressure, which reflect fluid volume loss.
A patient is admitted to the ICU with a dx of unstable angina. Which drug(s) would the nurse expect the patient to receive? (SATA) a. ACE Inhibitor b. anti-platelet therapy c. thrombolytic therapy d. prophylactic therapy e. IV nitroglycerin
Correct answers: a, b, e Rationale: In addition to oxygen, several drugs may be used to treat unstable angina (UA): IV nitroglycerin, aspirin (chewable), and morphine. For patients with UA with negative cardiac biomarkers and ongoing angina, a combination of aspirin, heparin, and a glycoprotein IIb/IIIa inhibitor (e.g., eptifibatide [Integrilin]) is recommended. ACE inhibitors decrease myocardial oxygen demand by producing vasodilation, reducing blood volume, and slowing or reversing cardiac remodeling.
In teaching a patient about CAD, the nurse explains that the changes that occur in this disorder are (SATA) a. diffuse involvement of plaque formation in coronary veins b. abnormal levels of cholesterol, especially LDL c. accumulation of lipid and fibrous tissue within the coronary arteries d. development of angina d/t decreased blood supply to muscle of heart e. chronic vasoconstriction of coronary arteries leading to permanent vasospasm
Correct answers: b, c, d Rationale: Atherosclerosis is the major cause of coronary artery disease (CAD) and is characterized by a focal deposit of cholesterol and lipids, primarily within the intimal wall of the artery. The endothelial lining of the coronary arteries becomes inflamed from the presence of unstable plaques and the oxidation of low-density lipoprotein (LDL) cholesterol. Fibrous plaque causes progressive changes in the endothelium of the arterial wall. The result is a narrowing of the vessel lumen and a reduction in blood flow to the myocardial tissue.
Which are clinical findings in a person with an acute lower extremity VTE (sata) a. pallor and coolnesss of foot and calf b. mild to moderate calf pain and tenderness c. grossly diminished or absent pedal pulses d. unilateral edema and induration of the thigh e. palpable cord along a superficial varicose vein
Correct answers: b, d Rationale: The patient with lower extremity venous thromboembolism (VTE) may or may not have unilateral leg edema, extremity pain, a sense of fullness in the thigh or calf, paresthesias, warm skin, erythema, or a systemic temperature greater than 100.4° F (38° C). If the calf is involved, it may be tender to palpation.
