Chapter 36 and 37
Which group of drugs will the nurse plan to include when teaching a patient who has a new diagnosis of peripheral artery disease (PAD)? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants
a. Statins Research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other drug categories in PAD. Chapter 37: Vascular Disorders
When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial blood pressure (BP) of 147/82 mm Hg and an ankle pressure of 112/74 mm Hg. The nurse calculates the patient's ankle-brachial index (ABI) as ________ (round up to the nearest hundredth).
ANS: 0.76 The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP. Chapter 37: Vascular Disorders
Which patient statement to the nurse is most consistent with the diagnosis of venous Insufficiency? a. "I can't get my shoes on at the end of the day." b. "I can't ever seem to get my feet warm enough." c. "I have burning leg pain after I walk two blocks." d. "I wake up during the night because my legs hurt."
a. "I can't get my shoes on at the end of the day." Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease. Chapter 37: Vascular Disorders
4. When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is appropriate for the nurse to include? a. Arrange for placement of a long-term IV catheter. b. Monitor labs for levels of streptococcal antibodies. c. Teach the importance of completing all oral antibiotics. d. Encourage the patient to begin regular aerobic exercise.
a. Arrange for placement of a long-term IV catheter. Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy. Chapter 36: Inflammatory and Structural Heart Disorders
27. Two days after an acute myocardial infarction (MI), a patient reports stabbing chest pain that increases with a deep breath. Which action will the nurse take first? a. Auscultate the heart sounds. b. Check the patient's temperature. c. Give PRN acetaminophen (Tylenol). d. Notify the patient's health care provider.
a. Auscultate the heart sounds. The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature and notifying the health care provider are also appropriate actions but would not be done before listening for a rub. Acetaminophen (Tylenol) is not effective for pericarditis pain. An analgesic would not be given before assessment of a new symptom. Chapter 36: Inflammatory and Structural Heart Disorders
The nurse is developing a discharge teaching plan for a patient diagnosed with thromboangiitis obliterans (Buerger's disease). Which expected outcome has the highest priority for this patient? a. Cessation of all tobacco use b. Control of serum lipid levels c. Maintenance of appropriate weight d. Demonstration of meticulous foot care
a. Cessation of all tobacco use Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease. Chapter 37: Vascular Disorders
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. Obtain vital signs. b. Teach wound care. c. Assess pedal pulses. d. Check the wound site.
a. Obtain vital signs. Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's 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. Chapter 37: Vascular Disorders
16. A patient with aortic stenosis has acute pain due to decreased coronary blood flow. What would be an appropriate nursing intervention for this patient? 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. Promote rest to decrease myocardial oxygen demand. 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. Chapter 36: Inflammatory and Structural Heart Disorders
A patient who is 2 days post femoral popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/VN) caring for the patient requires the registered nurse (RN) to intervene? a. The LPN/VN tells the patient sit in a chair for 2 hours. b. The LPN/VN gives the prescribed aspirin after breakfast. c. The LPN/VN assists the patient to walk 40 ft in the hallway. d. The LPN/VN places the patient in Fowler's position for meals.
a. The LPN/VN tells the patient sit in a chair for 2 hours. The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for venous thromboembolism (VTE). The other actions by the LPN/LVN are appropriate. Chapter 37: Vascular Disorders
Which action by the patient with newly diagnosed Raynaud's phenomenon best demonstrates that the nurse's teaching about managing the condition has been effective? a. The patient exercises indoors during the winter months. b. The patient immerses hands in hot water when they turn pale. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).
a. The patient exercises indoors during the winter months. Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm rather than hot water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking NSAIDs with Raynaud's phenomenon. Chapter 37: Vascular Disorders
26. The nurse is caring for a patient with aortic stenosis. Which assessment data would be most important to report to the health care provider? a. The patient reports 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. The patient reports chest pressure when ambulating. 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. Chapter 36: Inflammatory and Structural Heart Disorders
A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate? a. "Taking both blood thinners greatly reduces the risk for another clot to form." b. "Enoxaparin will work right away, but warfarin takes several days to begin preventing clots." c. "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming." d. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner."
b. "Enoxaparin will work right away, but warfarin takes several days to begin Low-molecular-weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE. Anticoagulants do not thin the blood. Chapter 37: Vascular Disorders
The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). Which patient statement indicates a need for additional teaching? a. "I should get a Medic Alert device stating that I take warfarin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the warfarin." d. "I will check with my health care provider before I begin any new drugs."
b. "I should reduce the amount of green, leafy vegetables that I eat." Teach patients taking warfarin to follow a consistent diet regarding foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate. Chapter 37: Vascular Disorders
. The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction? a. "I will buy loose clothes that do not bind across my legs or waist." b. "I will use a heating pad on my feet at night to increase the circulation." c. "I will walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week." d. "I will change my position every hour and avoid long periods of sitting with my legs crossed."
b. "I will use a heating pad on my feet at night to increase the circulation." Chapter 37: Vascular Disorders
Which instructions should the nurse include in a teaching plan for an older adult patient newly diagnosed with peripheral artery disease (PAD)? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."
b. "It is very important that you stop smoking cigarettes." Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD. Chapter 37: Vascular Disorders
Which patient statement supports a history of intermittent claudication? a. "When I stand too long, my feet start to swell." b. "My legs cramp when I walk more than a block." c. "I get short of breath when I climb a lot of stairs." d. "My fingers hurt when I go outside in cold weather."
b. "My legs cramp when I walk more than a block." Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Shortness of breath that occurs with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease. Chapter 37: Vascular Disorders
After receiving change-of-shift report, which patient admitted to the emergency department should the nurse assess first? a. A 67-yr-old patient who has a gangrenous foot ulcer with a weak pedal pulse b. A 50-yr-old patient who is reporting sudden sharp and severe upper back pain c. A 39-yr-old patient who has right calf tenderness and swelling after a plane ride d. A 58-yr-old patient taking anticoagulants for atrial fibrillation who has black stools
b. A 50-yr-old patient who is reporting sudden sharp and severe upper back pain The patient's presentation of sudden sharp and severe upper back pain is consistent with dissecting thoracic aneurysm, which will require the most rapid intervention. The other patients also require rapid intervention but not before the patient with severe pain. Chapter 37: Vascular Disorders
What finding should the nurse expect during the assessment of a young adult with infective endocarditis (IE)? a. Substernal chest pressure b. A new regurgitant murmur c. A pruritic rash on the chest d. Involuntary muscle movement
b. A new regurgitant murmur New regurgitant murmurs occur in IE because vegetations on the valves prevent valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever. Chapter 36: Inflammatory and Structural Heart Disorders
6. How should the nurse assess the patient with pericarditis for evidence of a pericardial friction rub? a. Listen for a rumbling, low-pitched, systolic murmur over the left anterior chest. b. Auscultate with the diaphragm of the stethoscope on the lower left sternal border. c. Ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub. d. Feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction.
b. Auscultate with the diaphragm of the stethoscope on the lower left sternal border. Pericardial friction rubs are best heard with the diaphragm at the lower left sternal border. The nurse should ask the patient to hold his or her breath during auscultation to distinguish the sounds from a pleural friction rub. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation. Chapter 36: Inflammatory and Structural Heart Disorders
An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first? a. Draw blood for laboratory testing. b. Check the patient's blood pressure. c. Assess the patient for an abdominal bruit. d. Determine any family history of heart disease.
b. Check the patient's blood pressure. Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions may also be done, but they will not provide information to determine what interventions are needed immediately. Chapter 37: Vascular Disorders
5. A patient is admitted to the hospital with possible acute pericarditis. What diagnostic test would the nurse expect the patient to undergo? a. Blood cultures b. Echocardiography c. Cardiac catheterization d. 24-hour Holter monitor ANS: B
b. Echocardiography Echocardiograms are useful in detecting the presence of the pericardial effusions associated NURSINGTB.COM with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac catheterization and 24-hour Holter monitor are not diagnostic procedures for pericarditis. Chapter 36: Inflammatory and Structural Heart Disorders
Several hours after a patient had 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 45 mL. What should the nurse anticipate will be prescribed? a. Hemoglobin count b. Increased IV fluids c. Additional antibiotics d. Serum creatinine level
b. Increased IV fluids 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 patient's decreased urinary output. Chapter 37: Vascular Disorders
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. Assess the abdominal incision for redness. d. Counsel the patient to plan for a long recovery time.
b. Monitor fluid intake and urine output. 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. Chapter 37: Vascular Disorders
The nurse suspects cardiac tamponade in a patient who has acute pericarditis. How should the nurse assess for the presence of pulsus paradoxus? a. Subtract the diastolic blood pressure from the systolic blood pressure. b. Note when Korotkoff sounds are heard during both inspiration and expiration. c. Check the electrocardiogram (ECG) for variations in rate during the respiratory cycle. d. Listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.
b. Note when Korotkoff sounds are heard during both inspiration and expiration. Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus. The difference between the diastolic blood pressure and the systolic blood pressure is known as the pulse pressure. Chapter 36: Inflammatory and Structural Heart Disorders
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. Wrap both legs in a warming blanket. b. Notify the surgeon and anesthesiologist. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.
b. Notify the surgeon and anesthesiologist. 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 surgeon immediately because this is an emergency situation. Because pulses are marked before surgery, the nurse would know whether pulses were present before surgery before notifying the health care providers about the absent pulses. Because the patient's 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 patient's legs. Chapter 37: Vascular Disorders
The nurse is admitting a patient newly diagnosed with peripheral artery disease who takes clopidogrel. Which admission order should the nurse question? a. Cilostazol drug therapy b. Omeprazole drug therapy c. Use of treadmill for exercise d. Exercise to the point of discomfort
b. Omeprazole drug therapy Because the antiplatelet effect of clopidogrel is reduced when it is used with omeprazole, the nurse should clarify this order with the health care provider. The other interventions are appropriate for a patient with peripheral artery disease. Chapter 37: Vascular Disorders
23. Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement? a. Administer ceftriaxone 1 gram IV. b. Order blood cultures from two sites. c. Schedule a transesophageal echocardiogram. d. Give acetaminophen (Tylenol) PRN for fever.
b. Order blood cultures from two sites. Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before starting antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and acetaminophen administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority. Chapter 36: Inflammatory and Structural Heart Disorders
Which finding on a patient's nursing admission assessment is congruent with the initial medical diagnosis of a 6-cm thoracic aortic aneurysm? a. Low back pain b. Trouble swallowing c. Abdominal tenderness d. Changes in bowel habits
b. Trouble swallowing 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. Chapter 37: Vascular Disorders
33. After receiving information about four patients during change-of-shift report, which patient should the nurse assess first? a. Patient with acute pericarditis who has a pericardial friction rub. b. Patient who has just returned to the unit after balloon valvuloplasty. c. Patient who has hypertrophic cardiomyopathy and a heart rate of 116. d. Patient with a mitral valve replacement who has an anticoagulant scheduled.
b. Patient who has just returned to the unit after balloon valvuloplasty. The patient who has just arrived after balloon valvuloplasty will need assessment for complications such as bleeding and hypotension. The information about the other patients is consistent with their diagnoses and does not indicate any complications or need for urgent assessment or intervention. Chapter 36: Inflammatory and Structural Heart Disorders
32. After receiving change-of-shift report on four patients, which patient should the nurse assess first? a. Patient with rheumatic fever who has sharp chest pain with a deep breath. b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg. c. Patient with infective endocarditis who has a murmur and splinter hemorrhages. d. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases.
b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg. Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea, chest pain or tachycardia. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention. Chapter 36: Inflammatory and Structural Heart Disorders
24. Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider? a. Muscle aching b. Right flank pain c. Janeway's lesions on the palms d. Temperature 100.7° F (38.1° C)
b. Right flank pain Chapter 36: Inflammatory and Structural Heart Disorders
Which action should the nurse include in a community health program to decrease the incidence of rheumatic fever? a. Vaccinate high-risk groups in the community with streptococcal vaccine. b. Teach community members to seek treatment for streptococcal pharyngitis. c. Teach about the importance of monitoring temperature when sore throats occur. d. Teach about prophylactic antibiotics to those with a family history of rheumatic fever.
b. Teach community members to seek treatment for streptococcal pharyngitis. The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring temperature will not decrease the incidence of rheumatic fever. Chapter 36: Inflammatory and Structural Heart Disorders
28. The nurse is caring for a patient admitted with mitral valve regurgitation. Which information obtained by the nurse should be reported to the health care provider immediately? a. The patient has 4+ peripheral edema. b. The patient has diffuse bilateral crackles. c. The patient has a loud systolic murmur across the precordium. d. The patient has a palpable thrill felt over the left anterior chest.
b. The patient has diffuse bilateral crackles. 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. Chapter 36: Inflammatory and Structural Heart Disorders
3. Which assessment finding(s) indicate to the nurse that a patient with infective endocarditis has decreased cardiac output? a. Fever, chills, and diaphoresis b. Urine production of 25 mL/hr c. Increase in heart rate of 15 beats/min with walking d. Petechiae on the inside of the mouth and conjunctiva
b. Urine production of 25 mL/hr Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/min is normal with exercise. Chapter 36: Inflammatory and Structural Heart Disorders
9. The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history focuses on a pertinent risk factor for rheumatic fever? a. "Do you use any illegal IV drugs?" b. "Have you ever injured your chest?" c. "Have you had a recent sore throat?" d. "Do you have a family history of heart disease?"
c. "Have you had a recent sore throat?" Rheumatic fever occurs because of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and it would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever. rocess: Assessment MSC: NCLEX: Chapter 36: Inflammatory and Structural Heart Disorders
15. Which statement by a 23-yr-old patient who has mitral valve prolapse (MVP) without valvular regurgitation indicates that discharge teaching has been effective? a. "I will take antibiotics before any dental appointments." b. "I will limit physical activity to avoid stressing the heart." c. "I should avoid over-the-counter drugs that contain stimulants." d. "I should take an aspirin a day to prevent clots from forming on the valve."
c. "I should avoid over-the-counter drugs that contain stimulants." Patients with MVP should avoid using stimulant drugs because they 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. Chapter 36: Inflammatory and Structural Heart Disorders
11. The home health nurse is visiting a 30-yr-old patient recovering from rheumatic fever without carditis. Which statement by the patient indicates a need for further teaching? a. "I will need prophylactic antibiotic therapy for 5 years." b. "I can take aspirin or ibuprofen to relieve my joint pain." c. "I will be immune to future episodes of rheumatic fever after this infection." d. "I should call the health care provider if I am fatigued or have difficulty breathing."
c. "I will be immune to future episodes of rheumatic fever after this infection." Patients with a history of rheumatic fever are more susceptible to a second episode. Patients with rheumatic fever without carditis require prophylaxis until age 20 years and for a minimum of 5 years. The other patient statements are correct. Chapter 36: Inflammatory and Structural Heart Disorders
10. A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. The patient reports that joint discomfort prevents favorite activities such as taking a daily walk and sewing. What problem should be the focus of nursing interventions? a. Social isolation b. General anxiety c. Activity intolerance d. Altered body image
c. Activity intolerance The patient's joint pain will lead to difficulty with activity. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes. This patient did not provide any data to support a problem with social isolation, anxiety, or altered body image. Chapter 36: Inflammatory and Structural Heart Disorders
Which actions for a patient at risk for venous thromboembolism could the nurse delegate to unlicensed assistive personnel (UAP)? a. Monitor for any bleeding after anticoagulation therapy is started. b. Tell the patient to call immediately if any shortness of breath occurs. c. Apply sequential compression devices whenever the patient is in bed. d. Ask the patient about use of any herbal medicines or dietary supplements.
c. Apply sequential compression devices whenever the patient is in bed. UAP training includes the use of equipment that requires minimal nursing judgment, such as sequential compression devices. Patient assessment and teaching require more education and critical thinking and should be done by the registered nurse (RN). Chapter 37: Vascular Disorders
29. Which action by the nurse will determine if therapies ordered for a patient with chronic constrictive pericarditis are effective? a. Assess for the presence of a paradoxical pulse. b. Monitor for changes in the patient's sedimentation rate. c. Assess for the presence of jugular venous distention (JVD). d. Check the electrocardiogram (ECG) for ST segment changes.
c. Assess for the presence of jugular venous distention (JVD). Because the most common finding on physical examination for a patient with chronic constrictive pericarditis is jugular venous distention, a decrease in JVD indicates improvement. Paradoxical pulse, ST segment ECG changes, and changes in sedimentation rates occur with acute pericarditis but are not expected in chronic constrictive pericarditis. Chapter 36: Inflammatory and Structural Heart Disorders
A young adult patient tells the health care provider about experiencing cold, numb fingers and Raynaud's phenomenon is suspected. What type of testing should the nurse anticipate explaining to the patient? a. Hyperglycemia b. Hyperlipidemia c. Autoimmune disorders d. Coronary artery disease
c. Autoimmune disorders Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis. Patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hyperglycemia, or coronary artery disease. Chapter 37: Vascular Disorders
The health care provider prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which action should the nurse include in the plan of care? a. Obtain a Doppler for monitoring bilateral pedal pulses. b. Decrease the infusion when the PTT value is 65 seconds. c. Avoid giving IM medications to prevent localized bleeding. d. Have vitamin K available in case reversal of the heparin is needed.
c. Avoid giving IM medications to prevent localized bleeding. Intramuscular injections are avoided in patients receiving anticoagulation to prevent hematoma formation and bleeding from the site. A PTT of 65 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE. Chapter 37: Vascular Disorders
The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure of 138/88 mm Hg d. 25 mL of urine output over the past hour
c. Blood pressure of 138/88 mm Hg The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that -blockers or other antihypertensive drugs can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action. Chapter 37: Vascular Disorders
14. A 46-yr-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge? a. Sitting at the work counter, rather than standing, is recommended. b. Exercise, such as walking or jogging, can cause recurrence of varicosities. c. Elastic compression stockings should be applied before getting out of bed. d. Taking an aspirin daily will help prevent clots from forming around venous valves.
c. Elastic compression stockings should be applied before getting out of bed. Elastic compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to prevent venous thrombosis and would not be recommended for a patient who had just had sclerotherapy. Chapter 37: Vascular Disorders
31. The nurse is assessing a patient with myocarditis before giving a scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider? a. Fatigue b. Leukocytosis c. Irregular pulse d. Generalized myalgia
c. Irregular pulse Myocarditis predisposes the heart to digoxin-associated dysrhythmias and toxicity. The other findings are common symptoms of myocarditis and there is no urgent need to report these. Chapter 36: Inflammatory and Structural Heart Disorders
25. Which finding by the nurse assessing a patient with acute pericarditis should be reported immediately to the health care provider? a. Pulsus paradoxus 8 mm Hg b. Blood pressure (BP) of 168/94 mm Hg c. Jugular venous distention (JVD) to jaw level d. Level 6 (0 to 10 scale) chest pain with a deep breath
c. Jugular venous distention (JVD) to jaw level The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis. The BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis. Chapter 36: Inflammatory and Structural Heart Disorders
14. A 21-yr-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 is needed after mechanical valve replacement. d. Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.
c. Lifelong anticoagulant therapy is needed after mechanical valve replacement. 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. Chapter 36: Inflammatory and Structural Heart Disorders
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. Hypoactive bowel sounds c. Maroon-colored liquid stool d. Abdominal pain with palpation
c. Maroon-colored liquid stool Loose, bloody (maroon-colored) 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. Chapter 37: Vascular Disorders
17. An older adult patient who had a mitral valve replacement with a mechanical valve is taking warfarin. What should the nurse include in discharge teaching? a. Use of daily aspirin for anticoagulation. b. Correct method for taking the radial pulse. c. Need for frequent laboratory blood testing. d. Plan to avoid any physical activity for 1 month.
c. Need for frequent laboratory blood testing. 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 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. Chapter 36: Inflammatory and Structural Heart Disorders
Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Report of right calf pain b. Erythema of right lower leg c. New onset shortness of breath d. Temperature of 100.4° F (38° C)
c. New onset shortness of breath New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as O2 administration and notification of the health care provider. The other findings are typical of VTE. Chapter 37: Vascular Disorders
18. A patient recovering from heart surgery develops pericarditis and reports level 6 (0 to 10 scale) chest pain with deep breathing. Which prescribed PRN medication will be the most appropriate for the nurse to give? a. Fentanyl 1 mg IV b. IV morphine sulfate 4 mg c. Oral ibuprofen (Motrin) 600 mg d. Oral acetaminophen (Tylenol) 650 mg
c. Oral ibuprofen (Motrin) 600 mg The pain associated with pericarditis is caused by inflammation, so nonsteroidal antiinflammatory drugs (e.g., ibuprofen) are most effective. Opioid analgesics and acetaminophen are not very effective for the pain associated with pericarditis. Chapter 36: Inflammatory and Structural Heart Disorders
22. Which patient will need the nurse to plan discharge teaching about prophylactic antibiotics before dental procedures? 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. Patient who had a mitral valve replacement with a mechanical valve 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. Chapter 36: Inflammatory and Structural Heart Disorders
34. The nurse who works in the vascular clinic has several patients with venous insufficiency. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/VN)? a. Patient who has a history of venous thromboembolism and reports dyspnea. b. Patient who has been reporting increased edema and skin changes in the legs. c. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. d. Patient who needs teaching about compression stockings for venous insufficiency.
c. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. LPN education and scope of practice includes wound care. The other patients, which require more complex assessments or education, should be managed by the RN. Chapter 37: Vascular Disorders
A patient has pain due to acute pericarditis. What is an appropriate nursing intervention for this problem? a. Teach the patient to take deep, slow breaths to control the pain. b. Force fluids to 3000 mL/day to decrease fever and inflammation. c. Place the patient in Fowler's position, leaning forward on the table. d. Provide a fresh ice bag every hour for the patient to place on the chest.
c. Place the patient in Fowler's position, leaning forward on the table. Sitting upright and leaning forward often will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep breaths will tend to increase pericardial pain. Ice does not decrease this type of inflammation and pain. Chapter 36: Inflammatory and Structural Heart Disorders
A patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe. What should the nurse expect to find on assessment? a. Dilated superficial veins. b. Swollen, dry, scaly ankles. c. Prolonged capillary refill in all the toes. d. Serosanguineous drainage from the ulcer.
c. Prolonged capillary refill in all the toes. Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease. Chapter 37: Vascular Disorders
19. What nursing assessment finding for a patient with infective endocarditis would be consistent with embolized vegetations from the tricuspid valve? a. Flank pain b. Splenomegaly c. Shortness of breath d. Mental status changes
c. Shortness of breath Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, changes in mental status, and splenomegaly would be associated with embolization from the left-sided valves. Chapter 36: Inflammatory and Structural Heart Disorders
13. Which finding for a patient with mitral valve stenosis would be of most concern to the nurse? a. Diastolic murmur b. Peripheral edema c. Shortness of breath on exertion d. Right upper quadrant tenderness
c. Shortness of breath on exertion 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 hypoxemia, which is a priority. Chapter 36: Inflammatory and Structural Heart Disorders
Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that the nurse needs further education about the drug? a. The nurse avoids rubbing the site after giving the injection. b. The nurse injects the drug into the abdominal subcutaneous tissue. c. The nurse ejects the air bubble from the syringe before giving the drug. d. The nurse does not check partial thromboplastin time (PTT) before giving the drug.
c. The nurse ejects the air bubble from the syringe before giving the drug. The air bubble is not ejected before giving fondaparinux to avoid loss of drug. The other actions by the nurse are appropriate for subcutaneous administration of a low-molecular-weight heparin (LMWH). LMWHs typically do not require ongoing PTT monitoring and dose adjustment. Chapter 37: Vascular Disorders
1. The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE? a. "Do you have a history of a heart attack?" b. "Is there a family history of endocarditis?" c. "Have you had any recent immunizations?" d. "Have you had dental work done recently?"
d. "Have you had dental work done recently?" Dental procedures place the patient with a prosthetic mitral valve at risk for IE. Myocardial infarction, immunizations, and a family history of endocarditis are not risk factors for IE. Chapter 36: Inflammatory and Structural Heart Disorders
30. Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's NURSINGTB.COM discharge teaching about self-management has been effective? a. "I will avoid taking aspirin or other antiinflammatory drugs." b. "I can restart my exercise program that includes hiking and biking." c. "I will need to limit my intake of salt and fluids even in hot weather." d. "I will take antibiotics before my teeth are cleaned at the dental office."
d. "I will take antibiotics before my teeth are cleaned at the dental office." Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use prophylactic antibiotics for any procedure that may cause bacteremia. The other statements indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt (unless ordered), aspirin, or nonsteroidal antiinflammatory drugs. Chapter 36: Inflammatory and Structural Heart Disorders
The nurse is caring for a patient with mitral regurgitation. Referring to the figure below, where should the nurse listen to best hear a murmur typical of mitral regurgitation? a. 1 b. 2 c. 3 d. 4
d. 4 Sounds from the mitral valve are best heard at the apex of the heart, fifth intercostal space, midclavicular line. Chapter 36: Inflammatory and Structural Heart Disorders
Which topic should the nurse include in teaching for a patient with a venous stasis ulcer on the lower leg? a. Need to increase carbohydrate intake b. Methods of keeping the wound area dry c. Purpose of prophylactic antibiotic therapy d. Application of elastic compression stockings
d. Application of elastic compression stockings Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist dressings are used to hasten wound healing. Chapter 37: Vascular Disorders
Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.
d. Help the patient to use a pillow to splint while coughing. Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RNs. Chapter 37: Vascular Disorders
A patient is being evaluated for postthrombotic syndrome. Which assessment will the nurse perform? a. Ask about leg pain with exercise. b. Determine the ankle-brachial index. c. Assess capillary refill in the patient's toes. d. Inspect for presence of lipodermatosclerosis.
d. Inspect for presence of lipodermatosclerosis. Clinical signs of postthrombotic syndrome include lipodermatosclerosis. In this situation, the skin on the lower leg becomes scarred, and the leg becomes tapered like an "inverted bottle." The other assessments would be done for patients with peripheral arterial disease. Chapter 37: Vascular Disorders
An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. After the nurse notifies the health care provider, what should the nurse do next? a. Apply a compression stocking to the leg. b. Elevate the leg above the level of the heart. c. Assist the patient in gently exercising the leg. d. Keep the patient in bed in the supine position.
d. Keep the patient in bed in the supine position. The patient's history and clinical manifestations are consistent with acute arterial occlusion. Resting the leg will decrease the O2 demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg. Chapter 37: Vascular Disorders
20. A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient? a. A heart transplant should be scheduled as soon as possible. b. Elevating the legs above the heart will help relieve dyspnea. c. Careful compliance with diet and medications will prevent heart failure. d. Notify the health care provider about symptoms such as shortness of breath.
d. Notify the health care provider about symptoms such as shortness of breath. The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). The patient with terminal or end-stage cardiomyopathy may consider heart transplantation. Chapter 36: Inflammatory and Structural Heart Disorders
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism of the left lower leg. Which action by the nurse is best? a. The patient's bed is placed in the Trendelenburg position. b. Two pillows are positioned under the calf of the affected leg. c. The bed is elevated at the knee and pillows are placed under both feet. d. One pillow is placed under the thighs and 2 pillows are under the lower legs.
d. One pillow is placed under the thighs and 2 pillows are under the lower legs. The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing 2 pillows under the feet and another under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level. Chapter 37: Vascular Disorders
A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though." What focused assessment should the nurse make? a. Look for the presence of tortuous veins bilaterally on the legs. b. Ask about any skin color changes that occur in response to cold. c. Assess for unilateral swelling, redness, and tenderness of either leg. d. Palpate for the presence of dorsalis pedis and posterior tibial pulses.
d. Palpate for the presence of dorsalis pedis and posterior tibial pulses. The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism. Chapter 37: Vascular Disorders
21. The nurse is obtaining a health history from a 24-yr-old patient with hypertrophic cardiomyopathy (CMP). Which information obtained by the nurse is most important in planning care? a. The patient had a recent upper respiratory infection. b. The patient has a family history of coronary artery disease. c. The patient reports using cocaine "a few times" as a teenager. d. The patient's 29-yr-old brother died from a sudden cardiac arrest.
d. The patient's 29-yr-old brother died from a sudden cardiac arrest. About half of all cases of hypertrophic CMP have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people. The information about the patient's brother will be helpful in planning care (e.g., an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against the use of stimulant drugs, but the limited past history indicates that the patient is not currently at risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy but not for hypertrophic CMP. Chapter 36: Inflammatory and Structural Heart Disorders
Which risk factor should the nurse focus on when teaching a patient who has a 5-cm abdominal aortic aneurysm? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension
d. Uncontrolled hypertension All the factors contribute to the patient's risk, but only hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm. Chapter 37: Vascular Disorders
34. Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit? a. Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome. b. Obtain a list of herbal medications used at home while admitting a new patient with pericarditis. c. Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy. d. Watch the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.
d. Watch the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates. Under the supervision of registered nurses (RNs), UAPs check the patient's cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN. Chapter 36: Inflammatory and Structural Heart Disorders