FINAL FOR NSG 229
The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following?
"I should reduce the amount of green, leafy vegetables that I eat."
After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective?
"I will call an ambulance if I still have pain after taking three nitroglycerin 5 minutes apart."
Which statement by a patient indicates additional teaching is required about the medication warfarin?
"I will increase the intake of green, leafy vegetables for a more healthful diet."
In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective?
"I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."
After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective?
"It is important not to suddenly stop taking the carvedilol."
A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make?
"What do you think caused your chest pain?"
The nurse should instruct a patient taking alteplase to immediately report which symptom(s) to the health care provider?
1. Nosebleeds 2. Tarry stools 3. Bleeding gums
A 198-lb patient is to receive a dobutamine infusion at 5 mcg/kg/min. The label on the infusion bag states: dobutamine 250 mg in 250 mL of normal saline. When setting the infusion pump, the nurse will set the infusion rate at how many milliliters per hour?
27
The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?
48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain
After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first?
A 59-yr-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI)
During the administration of the thrombolytic agent to a patient with an acute myocardial infarction, the nurse should stop the drug infusion if the patient experiences:
A decrease in level of consciousness
When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that:
Additional diagnostic testing will be required
Which nursing observation would indicate that the nurse hold the medication warfarin (Coumadin)?
An INR of 4.8
A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. Teaching for this patient would include information about:
Anticoagulant therapy
A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which action should the nurse take next?
Apply the transcutaneous pacemaker (TCP) pads.
When titrating IV nitroglycerin for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the drug?
Ask about chest pain
When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first?
Attach the heart monitor
A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom?
Auscultate for a pericardial friction rub.
A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first?
Auscultate the breath sounds
To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory test result will the nurse plan to review?
B-type natriuretic peptide (BNP)
What do you include for a pt who has heart failure and a reduces ejection fraction?
Benefits and effects of ACE inhibitor
The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider?
Bilateral crackles in the mid-lower lobes.
An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider?
Blood pressure (BP) of 88/42 mm Hg
A patient's heart monitor shows sinus rhythm, rate 64. The PR interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next?
Call the health care provider before giving scheduled metoprolol (Lopressor).
A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to best determine whether the patient has had an AMI?
Cardiac Specific Troponin
A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to best determine whether the patient has had an AMI?
Cardiac-specific troponin
Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes?
Collect a detailed diet history
A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
Crackles
A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which nursing diagnosis is a priority for the patient?
Decreased cardiac output related to cardiogenic shock
To improve the physical activity level for a mildly obese 71-year-old patient, which action should the nurse plan to take?
Determine what kind of physical activities the patient usually enjoys.
While doing the hospital admission assessment for a thin older adult, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take next?
Document the finding in the patient chart.
A patient who has chest pain is admitted to the emergency department (ED), and all of the following are ordered. Which one should the nurse arrange to be completed first?
Electrocardiogram (ECG)
Which action by a new registered nurse (RN) who is orienting to the telemetry unit indicates a good understanding of the treatment of heart dysrhythmias?
Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block
Which action will the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient?
Have the patient sit in a chair with the feet flat on the floor
A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea. His blood pressure measures 238/118 mm Hg. Which question should the nurse ask first?
Have you been taking all of your blood pressure medications as directed?
A 52-year-old man is admitted to the emergency department with severe chest pain. On what basis would the nurse suspect an MI?
He reports he has had no relief of the pain with rest or position change
Which information is most important for the nurse to include when teaching a patient with newly diagnosed hypertension?
Hypertension is usually asymptomatic until target organ damage occurs.
A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective?
I will call for help when I need to get up to use the bathroom.
The nurse is preparing discharge instructions for a client who was prescribed enalapril for treatment of hypertension. Which statement would the nurse give further teaching on
I will increase my dietary intake of foods high in potassium
when patient who is diagnosed with an MI is not relieved of chest pain with IV nitroglycerin, which medication will the nurse expect to be used?
IV morphine sulfate
A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All of the following medications have been ordered for the patient. The nurses priority action will be togive IV morphine sulfate 4 mg.
IV morphine sulfate 4 mg.
Which is probably the most important criterion on which to base the decision to report suspected child abuse?
Incompatibility between the history and injury observed
An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?
Increase the rate for the sodium nitroprusside infusion.
What do inotropic, dronotropic, and chronotropic drugs do
Ino= force of contraction, Drono= contraction/ electrical current of the heart, Chrono= beats of the heart
Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider?
No change in the patient's reported level of chest pain.
The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient?
No regular physical exercise
The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD) when lying flat in bed. Which follow-up action should the nurse take next?
Observe for JVD with the patient elevated 45 degrees.
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?
Obtain vital signs
The nurse is admitting a patient newly diagnosed with peripheral artery disease. Which admission order should the nurse question?
Omeprazole drug therapy
Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse?
Oxygen saturation of 88%
Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider?
Pallor and weakness of the right hand
A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as
Paroxysmal nocturnal dyspnea
The nurse is caring for a 70-year-old who uses hydrochlorothiazide (HydroDIURIL) and enalapril (Norvasc), but whose self-monitored blood pressure (BP) continues to be elevated. Which patient information may indicate a need for a change?
Patient uses ibuprofen (Motrin) daily to treat osteoarthritis
Which patient at the cardiovascular clinic requires the most immediate action by the nurse?
Patient with stable angina whose chest pain has recently increased in frequency
Patient has a newly inserted Central line, how to keep out infection the best
Performing line care, using aseptic technique, minimizing holding of the line, and ensure occlusive dressing is applied
The nurse is caring for a client with heart failure. The nurse knows that the client is experiencing right-sided heart failure based on which assessment?
Pitting edema in the bilateral legs
A patient's heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, apneic, and pulseless. Which action should the nurse take first?
Preform immediate defibrillation
Which is a common characteristic of those who sexually abuse children?
Pressure victim into secrecy
When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse?
Report of severe chest pain
Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain?
ST-segment Elevation
The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?
Serum creatinine of 2.8 mg/dL
Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider?
Serum potassium of 2.9 mEq/L
A 53-year-old patient with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most appropriate?
The choice of a patient for a heart transplant depends on many different factors.
The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is caused by an acute myocardial infarction (AMI)?
The pain has lasted longer than 30 minutes
After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective?
The patient has a glass of low-fat milk with each meal.
When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider?
The patient is allergic to shellfish
The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The laboratory test result most helpful in indicating myocardial damage will be:
Troponins T and I
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, and QRS complex wide and distorted, and QRS duration of 0.18 second. The nurse interprets the patient's cardiac rhythm as:
Ventricular fibrillation
A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?
Warm, pink and dry skin
A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction. Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy?
What time did your chest pain begin?
IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops:
a systolic BP <90 mm Hg
Nursing consideration when caring for an infant with FTT
a. Establish a structured routine and follow it consistently.
Children who are at risk for abuse
a. Unintentionally contributes to the abusing situation
Clinical manifestations of failure to thrive caused by behavioral problems resulting in inadequate intake of calories include:
a. avoidance of eye contact.
During a physical examination of an older patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The best follow-up action for the nurse to take will be to
assess for symptoms of left ventricular hypertrophy.
A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurses priority action will be to:
assess the patient for clinical manifestations of acute heart failure
To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
bell of the stethoscope with the patient in the left lateral position.
When auscultating over the patient's abdominal aorta, the nurse hears a loud humming sound. The nurse documents this finding as a
bruit
A 56-yr-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that
diagnosis, treatment, and ongoing monitoring will be needed
You are on a floor working with heart failure patients, who do you see first
digoxin level of 3.1
A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats, the nurse will anticipate that the patient may require
electrocardiographic (ECG) monitoring.
While assessing a 68 yr old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patients bed elevated 45 degrees. The nurse knows this finding indicates
increased right atrial pressure
The nurse suspects stable angina rather than MI pain in the patient who reports that his chest pain
is relieved by nitroglycerin
When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include:
milk, yogurt, and other milk products
A high pitched, scratchy, scraping sound that increases with exhalation and when the client leans forward is called a
pericardial friction rub. This is caused by inflammation of the pericardial sac.
The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." The nurse will need to call the health care provider about the:
postoperative patient with a BP of 116/42 mm Hg.
The nurse is caring for a patient who is receiving IV furesemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment bas been effective.
reduced dyspnea with the head of bed at 30 degrees
While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the water pill with the heart pill. When planning for the patients discharge the nurse will facilitate a
referral to a home health care agency
A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient's care?
sildenafil (Viagra)
