Exam 1 beeeeeeeeeeeitch medsurg
Two hours later, the patient is admitted to the cardiac stepdown unit with orders for a saline lock, cardiac diet, and oxygen at 2 L per nasal cannula with follow-up cardiac enzymes, and 12-lead ECG in 6 hours. One hour later, the patient reports severe shortness of breath. His oxygen saturation has dropped to 88%, BP is 96/54, and his monitor shows sinus tachycardia with a rate of 114. He reports mild chest pain. 1. What do you suspect is happening to the patient at this time? 2. The patient's laboratory values include troponin T 0.6 mg/mL. What is your best interpretation of this finding?
1. Based on the history of the recent CP and now increased shortness of breath with hypoxemia, the nurse can conclude that the patient may be experiencing heart failure. 2. Troponin T is elevated. This substance is not found in healthy patients; any rise indicates cardiac necrosis or acute MI.
During morning care, the patient develops shortness of breath, fatigue, and tachycardia. What is your interpretation of these findings? What interventions would you begin at this time?
1. The patient has developed activity intolerance from too much exertion. 2. Energy management - provide physical and emotional rest; arrange nursing care to provide periods of rest; provide assistance with any care the patient is unable to complete for himself; observe and document the patient's response to activity; as the patient improves, consult with a physical therapist; gradually increase activity based on the patient's responses.
Identify appropriate interventions for a patient experiencing inadequate oxygenation and tissue perfusion as a result of coronary artery disease. (Select all that apply.) A. Notify the physician. B. . Administer Tylenol for pain. C. Maintain or initiate an IV line. D. Apply oxygen via nasal cannula. E. Encourage interaction with family. F. Administer nitroglycerin sublingually.
A, C, D, F
Which cardiovascular disease results in the highest number of hospital admissions in the United States? A. Heart failure B. Rheumatic carditis C. Mitral valve disease D. Infective endocarditis
A. Heart failure Rationale: According to the American Heart Association, heart failure affects nearly 5.7 million Americans of all ages and is responsible for more hospitalizations than all forms of cancer combined. It is the number one cause for hospitalizations among Medicare patients. With improvement in survival of acute MIs and a population that continues to age, heart failure will continue to increase in prominence as a major health problem in the United States.
A patient is admitted with a weight loss of 2.3 kg over 36 hours, diarrhea, nausea, and vomiting. Based on this information, the nurse should assess which cardiovascular parameter more closely? A. Preload B. Afterload C. Heart rate D. Stroke volume
A. Preload The variables preload, afterload, and contractility influence stroke volume and preload is determined by the amount of blood returning to the heart from both the venous system (right heart) and the pulmonary system (left heart). Dehydration and overhydration directly influence preload. Blood flow from the heart into the systemic arterial circulation is measured clinically as cardiac output (CO), the amount of blood pumped from the left ventricle each minute. CO is derived from the patient's heart rate and stroke volume. Stroke volume is the amount of blood ejected by the left ventricle during each contraction.
After assessing the patient, you document the following: Jugular venous distention 2+ edema in feet and ankles Swollen hands and fingers Distended abdomen Bibasilar crackles on auscultation Productive cough with pink-tinged sputum What is your most likely interpretation of these findings? Biventricular failure Class IV heart failure Left-sided heart failure Right-sided heart failure
ANS: A The patient has key features of both right-sided and left-sided heart failure.
After morning care, the student nurse is to perform tracheostomy care under the RN's supervision. Which instructions does the RN give the student nurse? (Select all that apply.) A. Create a sterile field. B. Change trach ties if soiled. C. Remove old dressings and excess secretions. D. Suction the tracheostomy tube after the trach care. E. Clean the inner cannula with full-strength hydrogen peroxide.
ANS: A, B, C The student nurse should be taught to suction the tracheostomy tube before performing trach care if needed. The inner cannula should be cleaned with half-strength hydrogen peroxide, followed by sterile saline, and dried to prevent any of the solution from entering the tracheostomy.
Based on the patient's vital signs, what is the appropriate nursing action? A. Inform the provider of abnormal vital signs. B. Complete an assessment of airway and respiratory status. C. Provide patient teaching regarding relaxation techniques. D. Notify the Rapid Response Team for extra assistance.
ANS: B The patient may be experiencing some problems with her respiratory system. She had problems maintaining her saturation during the night, and her low oxygen saturation has not improved. Therefore, the nurse should complete an assessment to be able to report any abnormal findings to the health care provider. The nurse should not call the provider before doing this. The patient's anxiety may be related to the lack of oxygen. Patient teaching regarding relaxation techniques, once an assessment of the airway demonstrates patency, can be helpful in reducing symptoms associated with anxiety. Once this problem is resolved, her heart rate and respiratory rate are expected to return to normal. The Rapid Response Team should be notified only if the patient has a further decline in respiratory status.
The nurse understands which symptom to be a hallmark subjective sign of lung disease? A. Cough B. Dyspnea C. Chest pain D. Sputum production
Answer: A Rationale: Cough is a main sign of lung disease. Dyspnea (difficulty in breathing or breathlessness) is a subjective perception and varies among patients. A patient's feeling of dyspnea may not be consistent with the severity of the presenting problem. Sputum production may be associated with coughing and indicate an acute or chronic lung condition. Chest pain can occur with other health problems, as well as with lung problems.
As the assessment is completed, the nurse observes that the patient has a large amount of thick secretions visible in the trach. What is the priority nursing action? A. Add pulmonary toileting to daily interventions. B. Instruct the UAP to sit with the patient until she is calmer. C. Call the respiratory therapist for a stat bronchodilator treatment. D. Suction the artificial airway and remove the secretions.
ANS: D The most important intervention is to clear the airway. It is not necessary to call the respiratory therapist at this time. The secretions are tenacious and copious, which indicates a potential problem. Once her airway is clear, then all of the other options can be considered. The patient should be monitored very carefully and the health care provider notified about these findings.
The nurse understands which is the primary risk factor for lung cancer? A. Air pollution B. Cigarette smoking C. Chronic exposure to asbestos D. Occupational radiation exposure
Answer: A Rationale: According to the American Cancer Society, cigarette smoking remains the primary risk factor and is responsible for 9 out of 10 cases of lung cancer. Occupational exposure, secondhand smoke, asbestos, advancing age, and family history are additional risk factors
The nurse knows that under normal physiologic conditions of tissue perfusion, a patient will have what percent of oxygen dissociate from the hemoglobin molecule? A. 25% B. 50% C. 75% D. 100%
Answer B. Rationale: Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to perfuse tissues. Under normal conditions, 50% of hemoglobin molecules completely dissociate their oxygen molecules when blood perfuses tissues that have an oxygen tension (concentration) of 26 mm Hg. This is considered a "normal" point at which 50% of hemoglobin molecules are no longer saturated with oxygen.
A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action? A. Administer the rescue drugs. B. Take the patient's vital signs. C. Notify the patient's prescriber. D. Repeat the PEF reading to verify the results.
Answer: A Rationale: A PEF reading in the red zone indicates a range that is 50% below the patient's personal best PEF reading and indicates serious respiratory obstruction. The patient needs to receive rescue drugs immediately, and then the prescriber should be notified. Repeating the PEF reading and taking vital signs are also important, but doing so first delays the administration of the rescue drugs.
The nurse understands that patients with which dysrhythmia constitute the largest group of those hospitalized with dysrhythmias? A. Atrial fibrillation B. Sinus tachycardia C. Sinus bradycardia D. Ventricular fibrillation
Answer: A Rationale: Atrial fibrillation (AF) is the most common dysrhythmia seen in clinical practice. It is responsible for a third of hospitalizations for cardiac rhythm disturbances. Patients can live with this dysrhythmia, but most are treated with anticoagulation therapy to avoid possible blood clots.
You immediately notify the provider and within 45 minutes, the patient is transferred to the CCU for close monitoring. He is in serious condition and has developed crackles bilaterally, and his chest pain level has increased. What medications do you anticipate will be ordered for this patient? (Select all that apply.) A. Morphine B. Furosemide (Lasix) C. Atenolol (Tenormin) D. Prednisone (Deltasone) E. Acetaminophen (Tylenol)
Answer: A, B, C Based on the assessment findings, several medications will be ordered including IV diuretics (furosemide) and supplemental oxygen. If congestion and shortness of breath become critical, the patient may need to be placed on a ventilator until the fluid volume overload is under control. Once-a-day beta-adrenergic blocking agents (atenolol) decrease the size of the infarct, the occurrence of ventricular dysrhythmias, and mortality rates in patients with MI. A cardioselective beta-blocking agent is usually prescribed within the first 1 to 2 hours after an MI if the patient is hemodynamically stable. Beta blockers slow the heart rate and decrease the force of cardiac contraction. Medical interventions aim to relieve pain and decrease myocardial oxygen requirements through preload and afterload reduction. IV morphine is used to decrease pulmonary congestion and relieve pain.
While the Rapid Response Team is at the bedside, the patient's healthcare provider arrives. The provider writes several orders. Which order is most important for the nurse to implement immediately? A. Transfer to ICU B. Increase O2 to 3 L per nasal cannula C. ABGs 30 min after oxygen is increased D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP
Answer: B All of the provider's orders are very important, but based on the patient's severe shortness of breath, the first thing that should be done is to increase her oxygen. Once her oxygen is increased, the nurse should note the time and remember to call for stat ABGs in 30 minutes. The patient should then be transferred to the ICU as soon as possible. Once the patient arrives in the ICU, they can administer the one-time dose of Solu-Medrol.
The nurse is caring for a group of patients on the pulmonary unit. Which patient is at greatest risk for having pulmonary hypertension (PH)? A. 29-year old male who is overweight B. 32-year-old female with a family history of PH C. 43-year-old male with history of right-sided heart failure D. 50-year-old female with history of blood clots in the pulmonary artery
Answer: B Rationale: Family history is a primary risk assessment variable related to pulmonary hypertension (PH) and pulmonary artery hypertension (PAH). The disease usually develops between the ages of 20 to 60, and occurs more often in women. Other risk factors include obesity, heart and lung diseases, HIV infection, and history of pulmonary embolisms.
The nurse is caring for a patient with a cuffed tracheostomy and is aware the patient is at risk for developing which complication? A. Pneumothorax B. Tracheomalacia C. Subcutaneous emphysema D. Trachea-innominate artery fistula
Answer: B Rationale: Tracheomalacia can develop because of the constant pressure exerted by the cuff, causing tracheal dilation and erosion of cartilage. Pneumothorax can develop during any tracheostomy procedure if the thoracic cavity is accidentally entered. Subcutaneous emphysema can develop during any tracheostomy procedure if air escapes into fresh tissue planes of the neck. Trachea-innominate artery fistula can occur any time a malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy.
When using a 5-electrode lead ECG monitoring system, the nurse recognizes which lead is most optimal for detecting dysrhythmias? A. III B. V1 C. V5 D. aVR
Answer: B Rationale: Five-electrode ECG monitoring systems use four electrode leads to provide six limb lead tracings (leads I, II, III, aVR, aVL, or aVF) and the fifth electrode lead is a chest electrode that can be placed in any of the standard V1 to V6 locations. But in general, V1 is selected because of its value in detecting dysrhythmias (e.g., arrhythmia monitoring). (Source: Accessed March 25, 2014,
Ten minutes later, the patient is still in SVT and reports substernal chest pain and dizziness. Which action will you expect the physician to take to treat the dysrhythmia? Order a 12-lead ECG. Perform carotid massage. Administer amiodarone (Cordarone) IV push. Instruct the patient to take several deep breaths.
Answer: B The physician may perform vagal stimulation such as carotid massage, which may be successful in terminating the dysrhythmia; however, it may only be temporarily successful.
True or False: Flammable solutions containing high concentrations of alcohol or oil should not be used in rooms with oxygen. Therefore, hand hygiene using alcohol-based foams or gels should be avoided when caring for patients on oxygen therapy. A. True B. False
Answer: B (False) Rationale: Flammable solutions containing high concentrations of alcohol or oil are not used in rooms in which oxygen is in use. However this does not include alcohol-based hand rubs.
A 55-year-old woman with a long history of COPD and 40 years of smoking cigarettes is being admitted to the pulmonary stepdown unit from the ED. The ED nurse reports that the patient is on oxygen at 2 L per nasal cannula after having bronchodilator respiratory treatment in the ED. She has bilateral expiratory wheezes and crackles both anteriorly and posteriorly. A saline lock was placed in her right forearm for intermittent medications. Based on the patient's diagnosis, which clinical manifestations would the nurse expect to see when assessing this patient? (Select all that apply.) A. Bradycardia B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance
Answer: B, C, D, E The patient with COPD often has a barrel chest appearance, is short of breath, and may use accessory muscles when breathing. These patients tend to move slowly and are slightly stooped. Usually they sit with a forward-bending posture. With severe dyspnea, they exhibit activity intolerance and activities such as bathing and grooming are avoided.
During the evening shift, the patient has a bedside echocardiogram, which reveals an ejection fraction of 30%. Based on this finding, which medications might the provider order? (Select all that apply.) A. Multivitamin 1 PO each day B. Lisinopril (Zestril) 5 mg PO daily C. Digoxin (Lanoxin) 0.25 mg PO daily D. Ibuprofen (Advil) 200 PO mg twice daily E. Furosemide (Lasix) 20
Answer: B, C, E Commonly prescribed drug classes for patients with heart failure include ACE inhibitors (lisinopril), diuretics (furosemide), nitrates (digoxin), human B-type natriuretic peptides, inotropics, and beta-adrenergic blockers.
While suctioning a patient, vagal stimulation occurs. What is the appropriate nursing action? A. Instruct the patient to cough. B. Place the patient in a high Fowler's position. C. Oxygenate the patient with 100% oxygen. D. Instruct the patient to breathe slowly and deeply.
Answer: C Rationale: Vagal stimulation may occur during suctioning and result in severe bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or other dysrhythmias. If vagal stimulation occurs, stop suctioning immediately and oxygenate the patient manually with 100% oxygen. Repositioning the patient, slow deep breathing, and coughing will not address the cardiovascular effects of vagal stimulation.
The SVT resolves immediately after IV adenosine (Adenocard) is administered. Because the patient has experienced repeated episodes of symptomatic SVT, a cardiologist has been consulted and treatment options discussed. What is the preferred treatment for recurrent SVT? A. Atrial overdrive pacing B. Synchronized electrical shock C. Radiofrequency catheter ablation D. Daily administration of diltiazem (Cardizem)
Answer: C If SVT is continuous, the patient should be studied in the electrophysiology laboratory. The preferred treatment is radiofrequency catheter ablation. Radiofrequency ablation is a procedure that can cure many types of fast heart rates. Using special wires or catheters that are threaded into the heart, radiofrequency energy (low-voltage, high-frequency electricity) is targeted toward the area(s) causing the abnormal heart rhythm, permanently damaging small areas of tissue with heat. The damaged tissue is no longer capable of generating or conducting electrical impulses. If the procedure is successful, this prevents the dysrhythmia from being generated, thereby curing the patient.
A patient is brought to the ED after being hit by a car. He is unresponsive, has shallow breathing, and has an open femur fracture from which he has lost a significant amount of blood. The nurse anticipates which acid-base imbalance? A. Metabolic alkalosis B. Respiratory acidosis C. Metabolic acidosis and respiratory acidosis D. Metabolic alkalosis and respiratory alkalosis
Answer: C Rationale: Hypoperfusion associated with significant shift in intravascular volume and/or blood loss that may be experienced by patients with significant trauma, burn injuries, sepsis, shock states, or cardiac arrest are examples of problems leading to metabolic acidosis. Shallow breathing or ineffective ventilation causes respiratory acidosis. Combined acidosis is more severe than either metabolic acidosis or respiratory acidosis alone.
The nurse is reviewing the standing orders for a patient who was admitted for evaluation of chest pain. The patient has a history of chronic obstructive pulmonary disease (COPD) and his laboratory results and assessment reveal that he has mild respiratory acidosis. The nurse would question which order? A. Encourage oral fluids B. Keep head of bed elevated C. Oxygen therapy at 4 L/min as needed D. Bedrest with bathroom privileges only
Answer: C Rationale: The bedrest order will help the patient conserve energy. The upright position (mid-Fowler's to high-Fowler's position) helps increase lung expansion. Increasing fluid intake may reduce the thickness of lung secretions and assist in their removal. Oxygen therapy helps promote gas exchange for patients with respiratory acidosis. However, use caution when giving oxygen to patients with COPD and CO2 retention as evidenced by a high Paco2 level. The only breathing trigger for these patients is a decreased arterial oxygen level. Giving too much oxygen to these patients decreases their respiratory drive and may lead to respiratory arrest.
The patient's SVT returns after 30 minutes. What medication do you anticipate will be ordered for the patient? A. Magnesium sulfate 1 g IVP B. Lidocaine (Xylocaine) 75 mg IVP C. Adenosine (Adenocard) 6 mg IVP D. Mexiletine (Mexitil) 300 mg PO q8h
Answer: C The appropriate medication to administer is adenosine (Adenocard), which is the drug used for SVT. The nurse should give the medication as ordered to include 6 mg IV over 1 to 3 seconds followed by 20 mL saline flush. It may be repeated in 1 to 2 minutes if necessary. The nurse should monitor the patient's heart rate and rhythm carefully after administration of the medication. Be sure to have the crash cart available because a short period of asystole is common after administration. Bradycardia and hypotension may also occur.
The nurse understands that the expected assessment for the older adult related to the natural aging process of the respiratory system includes which finding? A. Tightening of the vocal cords B. Decrease in residual volume C. Decrease in the anteroposterior diameter D. Decrease in respiratory muscle strength
Answer: D Rationale: As a person ages, vocal cords become slack, changing the quality and strength of the voice; the anteroposterior diameter increases; respiratory muscle strength decreases; and the residual volume increases.
On a telemetry monitor, the nurse observes that a patient's heart rhythm is sustained ventricular tachycardia (VT). Upon assessment, the patient is alert and oriented with no reports of chest pain, but expresses feeling slightly short of breath. His blood pressure is 108/70. What is the nurse's first action? A. Synchronized cardioversion B. CPR and immediate defibrillation C. Administration of IV amiodarone (Cordarone) and dextrose D. Administration of oxygen and observation of the heart rhythm
Answer: D Rationale: Current advanced cardiac life support (ACLS) guidelines recommend administration of oxygen and observation of heart rhythm first, followed by administration of an IV antidysrhythmic agent such as amiodarone mixed with dextrose 5%. Synchronized cardioversion would be the next step. CPR and immediate defibrillation would be used only to treat unstable VT.
The nurse is evaluating the laboratory work of a patient who has uncontrolled metabolic acidosis. Which outcome would result from this condition? A. pH 7.40 B. Pao2 98 mm Hg C. Bicarbonate 38 mEq/L D. Serum potassium 5.7 mEq/L
Answer: D Rationale: Metabolic acidosis is reflected by several changes in ABG values. The pH is low (<7.35). The bicarbonate level is low (<21 mEq/L). The partial pressure of arterial oxygen (Pao2) is normal because gas exchange is adequate. The serum potassium level is often high in acidosis as the body attempts to maintain electroneutrality during buffering.
The patient is in the ICU for 3 days and then transferred back to the pulmonary stepdown unit. She is still slightly short of breath with exertion. Her O2 saturation is 99% on oxygen at 2 L per nasal cannula. She denies any shortness of breath when resting during the assessment. The provider plans to discharge the patient on home oxygen in the morning. What should the nurse include in this patient's discharge teaching?
Answer: Make sure that the patient understands any new medication regimen. She should be instructed to call 911 for any severe respiratory distress. Because she is being discharged with home oxygen, home health services should be arranged.
The patient's condition improves, and he is returned to the cardiac stepdown unit. He is to be discharged after 6 days in the hospital. What patient teaching should you provide before he is discharged from the hospital?
Assist the patient in securing personal medical identification alert devices that provide information regarding his heart condition. In collaboration with the interdisciplinary health care team, assess the patient for activity tolerance and help design an appropriate exercise regimen. Teach about the signs and symptoms of cardiovascular disease and when to seek medical assistance. Instruct him about all of his current medications and the most common side effects. Give him printed information as needed. Teach him the importance of decreasing the risk for CAD. Be sure that he has adequate support at home after discharge from the hospital.
In 2013, the ACA/AHA developed guidelines to reduce cardiovascular risk and decrease blood pressure. Which interventions relate to these guidelines? (Select all that apply.) A. Use only sugar in beverages. B. Engage in aerobic exercise 3 to 4 times per week. C. Develop a dietary plan that includes fish, legumes, and nuts. D. Include at least 3000 mg of sodium per day in the dietary plan. E. Encourage a dietary pattern of vegetables, fruits, and whole grains.
B, C, and E. The 2013 ACA/AHA Guidelines on Lifestyle Management to Reduce Cardiovascular Risk outline evidence-based dietary and exercise practices to help lower blood pressure (Eckel et al., 2013). These guidelines are similar to the Dietary Approaches to Stop Hypertension (DASH) and include: Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains. Consume low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts in the diet. Limit intake of sweets, sugar-sweetened beverages and red meats. Lower sodium intake to no more than 2400 mg of sodium per day; a limit of 1500 mg of sodium per day is preferred. Engage in aerobic physical activity 3 or 4 times a week. Each session should last for 40 minutes on average and involve moderate-to-vigorous physical activity
At the end of the visit, the provider prescribes hydrochlorothiazide (HydroDIURIL) 25 mg PO each morning to manage the patient's hypertension. Which statement do you include when teaching the patient about this drug? A. "This is a loop diuretic that decreases sodium reabsorption." B. "Eat foods rich in potassium, such as bananas and orange juice." C. "A potassium supplement will be prescribed along with this drug." D. "HydroDIURIL is a potassium-sparing diuretic that helps prevent the loss of essential potassium."
B. "Eat foods rich in potassium, such as bananas and orange juice." Hydrochlorothiazide is a thiazide diuretic. The most frequent side effect is hypokalemia, so it's important to teach patients the signs of low potassium, as well as which foods are rich in potassium. Some patients need a potassium supplement, but this is prescribed based on the patient's serum potassium level.
The older patient with coronary artery disease (CAD) is more likely to have what symptom if experiencing cardiac ischemia? A. Syncope B. Dyspnea C. Chest pain D. Depression
B. Dyspnea Chest pain may not be evident in the older patient with CAD. Associated symptoms such as unexplained dyspnea, confusion, or GI symptoms may be noted.
The nurse expects what outcome in a patient who is taking a beta blocker for mild heart failure? A. Improved urinary output B. Improved activity tolerance C. Increased myocardial contractility D. Increased myocardial oxygen
B. Improved activity tolerance Beta-blocker therapy for mild and moderate heart failure can lead to improvement in symptoms, including improved activity tolerance and less orthopnea.
After consulting with the provider, the following orders are received: Full liquid diabetic diet IV fluids 1000 mL .9 NS at 60 mL/hr Oxygen at 2 L per nasal cannula Blood cultures × 3 and urinalysis Tylenol grain × every 4 hr for temp above 101º F Cefazolin (Ancef) 1 g IVP every 8 hr Which of the provider's orders should the nurse implement first? A. IV fluids 1000 mL .9 NS at 60 mL/hr B. Oxygen at 2 L per nasal cannula C. Blood cultures and urinalysis D. Cefazolin (Ancef) 1 g IVP every 8 hr
B. Oxygen at 2 L per nasal cannula All of the provider's orders are very important. However, the most important one is oxygen therapy. Hypoxia is often seen with pneumonia, so it is very important that supplemental oxygen is started as soon as possible. IV fluids should be started to enhance pulmonary toileting, and the laboratory should be notified to draw the needed blood cultures. UAP can obtain the specimen for urinalysis. The blood cultures and the UA should be obtained before the IVP Ancef is administered.
A 51-year-old man came to the hospital 2 days ago for recurrent exacerbation of heart failure. He weighs 237 lbs and is 5' 8" tall. He has IV access in his left forearm and is on oxygen at 2 L per nasal cannula. When you assess the patient, he is sitting on the side of the bed and appears to be short of breath. He tells you that he has just returned from the bathroom. He is sweating and his nasal cannula is laying on the bedside table. Which action should you take first? A. Take his vital signs. B. Replace the nasal cannula. C. Sit him up in a bedside chair. D. Call the Rapid Response Team.
B. Replace the nasal cannula The patient has exerted himself in ambulating to and from the bathroom. He also has been without supplemental oxygen. The first action should be to replace his nasal cannula. He has a history of heart failure and will often require supplemental oxygen. Taking his vital signs can be done once his oxygen is restored. If he wants to sit up, he should be positioned in bed, not in a bedside chair. Calling the Rapid Response Team is not necessary.
An 83-year-old patient is brought to the ED reporting a productive cough with fever for the last 48 hours. She appears flushed and very short of breath when answering questions. She has a history of type 2 diabetes mellitus and hypertension, but no known allergies. A chest x-ray, CBC, and basic metabolic panel (electrolytes, BUN, creatinine) are drawn in the ED. A saline lock is inserted into her right forearm. She is admitted to the medical-surgical unit with a diagnosis of suspected pneumonia. The patient is assessed and a blood glucose level and vital signs are obtained upon arrival on the unit. Results are as follows: BG - 239 mg/dL BP - 138/88 mm Hg HR - 128 RR - 36 breaths/min O2 saturation - 88% (room air) Temp - 101.6º F Which vital sign or test result requires the nurse's immediate attention? A. Blood pressure B. Respiratory rate C. Temperature D. Blood glucose
B. Respiratory Rate All of the patient's vital signs are abnormal. However, the most important one to report immediately is her increased respirations (and decreased oxygen saturation). Even though a diagnosis has not been confirmed, it is very important to address these problems. The patient is experiencing tachypnea.
The nurse is assessing a patient who received a heart transplant. Which symptom suggests that the patient may be experiencing organ rejection? A. Fever B. Weight gain C. Tachycardia D. Hypertension
B. Weight gain Clinical manifestations of heart transplant rejection include shortness of breath, fatigue, fluid gain (edema, increased weight), abdominal bloating, new bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction (late sign).
The nurse understands that which assessment finding is the best indicator of fluid retention? A. Tachycardia B. Weight gain C. Crackles in the lungs D. Increased blood pressure
B. Weight gain Weight gain is the best indicator of fluid retention and is commonly called edema.
A patient is admitted with cough, fever, sore throat, progressive shortness of breath, diarrhea, and vomiting that developed after returning from a business trip overseas. The nurse suspects which illness is the likely cause of the patient's symptoms? A. Pneumonia B. Viral influenza C. Avian influenza D. Tuberculosis exposure
C. Avian influenza Rationale: The initial manifestations of avian influenza are similar to other respiratory infections but include cough, fever, sore throat, shortness of breath, pneumonia, diarrhea, vomiting, abdominal pain, and bleeding from the nose and gums. Assess whether the patient has recently (within the past 10 days) traveled to areas of the world affected by H5N1. Pneumonia and tuberculosis exposure will not present with gastrointestinal symptoms.
The nurse understands that which of the following is the most common manifestation of pneumonia in the older adult patient? A. Fever B. Cough C. Confusion D. Weakness
C. Confusion Rationale: The older adult with pneumonia often has weakness, fatigue, lethargy, confusion, and poor appetite. Fever and cough may be absent, but hypoxemia is usually present. The most common manifestation of pneumonia in the older adult patient is confusion from hypoxia rather than fever or cough.
What atypical symptoms might a woman who is having a myocardial infarction experience? A. Sudden, intermittent, stabbing chest pain B. Moderate ache in the chest that is worse on inspiration C. Indigestion, feelings of chronic fatigue, and a choking sensation D. Pain that spreads across the chest and back and/or radiates down the arm
C. Indigestion, feelings of chronic fatigue, and a choking sensation. Some patients, especially women, do not experience pain in the chest with a myocardial infarction, but instead feel discomfort or indigestion. Women often present with a "triad" of symptoms. In addition to indigestion or feeling of abdominal fullness, feelings of chronic fatigue despite adequate rest and feelings of "inability to catch one's breath" are also attributable to heart disease. The patient may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or viselike.
The next morning, the patient is taken to the cardiac catheterization laboratory. The cardiologist finds that there is an 80% blockage in the proximal LAD coronary artery. Which procedure is most likely to be performed to correct this condition? A. Coronary atherectomy B. Coronary artery bypass graft surgery C. PTCA with coronary artery stent placement D. Percutaneous transluminal coronary angioplasty (PTCA)
C. PTCA with coronary artery stent placement The most common complication of PTCA is re-blockage of the coronary artery. For this reason, a coronary stent is placed to keep the re-opened artery from closing again.
A patient presents to the ED and is diagnosed with an acute MI. The patient's spouse asks what type of damage has been caused by the "heart attack." What is the appropriate nursing response? A. "The pain is controlled, so there is no damage." B. "It will take years to know the extent of the damage to the heart muscle." C. "The medication will dilate the blood vessels and any damage will be corrected." D. "A heart attack evolves over several hours. We won't know the extent of the damage immediately."
D. "A heart attack evolves over several hours. We won't know the extent of the damage immediately." Infarction is a dynamic process that does not occur instantly. The MI evolves over a period of several hours. Controlled pain does not indicate that there is no cardiac muscle damage. The medications do vasodilate to prevent further damage. They do not correct damage that has already been incurred.
A patient with cardiovascular disease is prescribed a potassium-wasting diuretic. The nurse will recommend that the patient consume which food to help prevent hypokalemia? A. Dried figs B. Red apples C. Raw avocados D. Baked potatoes
D. Baked potatoes Many fruits, beans, and vegetables are high in potassium; however, a baked potato has approximately 1000 mg of potassium, an avocado has 180 mg, dried figs have 271 mg, and an apple has 160 mg. The patient should be encouraged to read nutrition labels for nutrient information as well.
Fifteen minutes after the oxygen is replaced via nasal cannula and he has rested, the patient denies being short of breath. You obtain an oxygen saturation, which is 96%. Based on this result, what should you do next? A. Call the provider as soon as possible. B. Encourage the patient to take some deep breaths. C. Increase the oxygen level to 5 L per nasal cannula. D. Continue the assessment, as 96% is considered acceptable.
D. Continue the assessment, as 96% is considered acceptable. Once the patient's oxygen is replaced, he denies shortness of breath. The supplemental oxygen and a period of rest resulted in his oxygen saturation being 96%, which is acceptable. The oxygen should not be increased, nor does he need to take deep breaths because the patient's SaO2 is normal and he is not short of breath.
What is the most common symptom associated with hypertension? A. Headache B. Slurred speech C. Fainting and dizziness D. Hypertension is often asymptomatic
D. Hypertension is often asymptomatic Hypertension is often asymptomatic and has become known as the "silent killer" due to its lack of symptoms. Headaches may occur but not always. Hypertension does not cause slurred speech or fainting.
A patient is experiencing hypotension, fever, chills, night sweats, and weight loss. Upon assessment, the nurse notes a displaced PMI. The nurse knows this collection of symptoms are associated most closely with which condition? A. Influenza B. Pneumonia C. Tuberculosis D. Pulmonary empyema
D. Pulmonary empyema Rationale: Patients with pneumonia, tuberculosis, and influenza may experience some or all of the symptoms of fever, chills, night sweats, and weight loss. However, because pulmonary empyema is a collection of pus in the pleural space that may cause compromised cardiac function, displaced point of maximal impulse (PMI), and hypotension may result.
A 28-year-old woman with a history of hypertension and tachycardia comes to the hospital clinic stating that she doesn't feel well. You connect her to a cardiac monitor and observe that she is in SVT with a rate varying between 160-180. She reports shortness of breath, palpitations, and weakness. She appears very nervous and anxious, and her BP is 88/56 mm Hg. What is your priority intervention?
Oxygen should be administered at 2 L per nasal cannula.
A patient was admitted with a diagnosis of respiratory failure 3 weeks ago. She required an artificial airway (tracheostomy) to help clear her secretions. The previous shift nurse reports that the patient had a very restless night with a drop in her O2 saturation level several times despite her O2 being set at 40% via trach collar. The previous shift nurse also reports that the patient experienced tachycardia and tachypnea during the night. Blood pressure: 128/84 mm Hg Heart rate: 114 (sinus tachycardia) Respiratory rate: 24 and labored Temperature: 99.4º F (axillary) O2 saturation: 91% on 40% O2 via trach collar Which of these findings are cause for concern?
The BP is within normal range and only slightly elevated. The temperature is only slightly elevated. Her heart rate is elevated; the nurse should check the patient's medications to see if she is on a bronchodilator or other medication that could cause her heart rate to increase. The priority concern is the increased respiratory rate and the decreased oxygen saturation despite the 40% oxygen setting.
When the patient arrives to the unit, she is assessed and is in acute respiratory distress. Her respirations are labored and her respiratory rate is 34. She states that she is severely short of breath. Her oxygen saturation is 82% on O2 at 2 L via nasal cannula. Based on these findings, what should the nurse do next?
The Rapid Response Team should be notified immediately. All of these assessment findings indicate acute respiratory difficulty. The oxygen saturation should be at least 90% on 2 L per NC.
Two hours later, the patient has a weak cough, crackles in both lower lobes, and an SaO2 reading of 90% by pulse oximetry. What interventions should be implemented by the nurse at this time?
The patient has developed problems with her airway. Interventions should include helping her to cough and deep breathe at least every 2 hours; teaching incentive spirometry every hour while awake; encouraging the patient to consume 3 L of fluid per day; monitoring intake and output; and administering bronchodilators if ordered.
Paramedics arrive at the ED with a 78-year-old man who presents with severe chest pain. In triage, he reports that he experienced chest pain for several hours before calling 911. He reports that he takes "heart medications" but he does not know their names. He rates his chest pain as a 9 on a 0-to-10 scale. Patient history includes an MI 6 years ago that resulted in stent placement for severe CAD. One stent was placed in the LAD and another in his circumflex artery. He states that his health care provider told him he also has heart failure. What laboratory tests do you anticipate the provider will order for this patient?
While there is no single ideal test to diagnose MI, the most common laboratory tests include troponins T and I, creatine kinase-MB (CK-MB), and myoglobin. These cardiac markers are specific for MI and cardiac necrosis. Troponins T and I and myoglobin rise quickly. CK-MB is the most specific marker for MI, but does not peak until about 24 hours after the onset of pain. CAD, Coronary artery disease; LAD, left anterior descending artery.
