NURS 435 Exam 1

A patient with chronic heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. "I plan to take the medication with food." b. "I should eat more potassium-rich foods." c. "I will call for help when I need to get up to use the bathroom." d. "I can expect to feel more short of breath for the next few days."

"I will call for help when I need to get up to use the bathroom." Rationale: Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The angiotensin-converting enzyme (ACE) inhibitors are potassium sparing, and the nurse should not teach the patient to purposely increase sources of dietary potassium. Increased shortness of breath is expected with the initiation of β-adrenergic blocker therapy for heart failure, not for ACE inhibitor therapy. ACE inhibitors are best absorbed when taken an hour before eating.

Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina? a. "The pain wakes me up at night." b. "The pain is level 3 to 5 (0 to 10 scale)." c. "The pain has gotten worse over the last week." d. "The pain goes away after a nitroglycerin tablet."

"The pain goes away after a nitroglycerin tablet." Rationale: Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

Answer: Activated partial thromboplastin time Rationale: Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

Which finding from a newly admitted adult patient's electrocardiogram (ECG) requires further investigation by the nurse? a. Isoelectric ST segment b. PR interval of 0.18 second c. QT interval of 0.38 second d. QRS interval of 0.14 second

Answer: QRS interval of 0.14 second Because the normal QRS interval is less than 0.12 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The PR interval and QT interval are within normal range and ST segment should be isoelectric (flat).

Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). How should the nurse explain the purpose of the heparin to the patient? a. "Heparin enhances platelet aggregation at the plaque site." b. "Heparin decreases the size of the coronary artery plaque." c. "Heparin prevents the development of new clots in the coronary arteries." d. "Heparin dissolves clots that are blocking blood flow in the coronary arteries."

Answer: "Heparin prevents the development of new clots in the coronary arteries." Rationale: Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

Which patient statement to the nurse indicates that the patient understands self-care for pernicious anemia? a. "I need to start eating more red meat and liver." b. "I will stop having a glass of wine with dinner." c. "I could choose nasal spray rather than injections of vitamin B12." d. "I will need to take a proton pump inhibitor such as omeprazole (Prilosec)."

Answer: "I could choose nasal spray rather than injections of vitamin B12." Rationale: Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I could take a stool softener if I feel constipated." b. "I can take the iron with orange juice before eating." c. "I should notify my health care provider if my stools turn black." d. "I will increase my fluid and fiber intake while I am taking iron."

Answer: "I should notify my health care provider if my stools turn black." Rationale: It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct.

Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective? a. "I can expect nausea as a side effect of nitroglycerin." b. "I should only take nitroglycerin when I have chest pain." c. "Nitroglycerin helps prevent a clot from forming and blocking blood flow to my heart." d. "I will call an ambulance if I have pain after taking 3 nitroglycerin 5 minutes apart."

Answer: "I will call an ambulance if I have pain after taking 3 nitroglycerin 5 minutes apart." Rationale: The emergency response system (ERS) should be activated when chest pain or other symptoms are not completely relieved after three sublingual nitroglycerin tablets taken 5 minutes apart. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset (e.g., nausea) is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

Which statement by a patient with newly diagnosed heart failure indicates to the nurse that teaching was effective? a. "I will take furosemide (Lasix) every day just before bedtime." b. "I will use the nitroglycerin patch whenever I have chest pain." c. "I will use an additional pillow if I am short of breath at night." d. "I will call the clinic if my weight goes up 3 pounds in a week."

Answer: "I will call the clinic if my weight goes up 3 pounds in a week." Rationale: Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 lb in 2 days or 3 to 5 lb in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as needed" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops rather than just compensating by further elevating the head of the bed.

The nurse is evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery. Which patient statement indicates that additional teaching is needed? a. "They will circulate my blood with a machine during surgery." b. "I will have incisions in my leg where they will remove the vein." c. "They will use an artery near my heart to go around the area that is blocked." d. "I will need to take aspirin every day after the surgery to keep the graft open."

Answer: "I will have incisions in my leg where they will remove the vein." Rationale: When the internal mammary artery is used, there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.

Which statement made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed? a. "I will switch from whole milk to 1% milk." b. "I like salmon and I will plan to eat it more often." c. "I can have a glass of wine with dinner if I want one." d. "I will miss being able to eat peanut butter sandwiches." ANS: D

Answer: "I will miss being able to eat peanut butter sandwiches." Rationale: Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monounsaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC 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? a. "I will sit down before I put the nitroglycerin under my tongue." b. "I will check my pulse rate before I take any nitroglycerin tablets." c. "I will put the nitroglycerin patch on as soon as I get any chest pain." d. "I will remove the nitroglycerin patch before taking sublingual nitroglycerin."

Answer: "I will sit down before I put the nitroglycerin under my tongue." Rationale: The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin. Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.

Which statement by a patient indicates that the nurse's teaching about management of primary genital herpes has been effective? a. "I will use acyclovir ointment on the area to relieve the discomfort." b. "I will use condoms for intercourse until the medication is all gone." c. "I will take the oral acyclovir (Zovirax) every 8 hours for the next week." d. "I will need to take all of the medication to be sure the infection is cured."

Answer: "I will take the oral acyclovir (Zovirax) every 8 hours for the next week." Rationale: The treatment regimen for primary genital herpes infections includes acyclovir 400 mg 3 times daily for 7 to 10 days. The patient is taught to abstain from intercourse until the lesions are gone. Condoms should be used even when the patient is asymptomatic. Acyclovir ointment is not effective in treating lesions or reducing pain. Herpes infection is chronic and recurrent.

The nurse evaluates that discharge teaching about the management of a new permanent pacemaker has been effective when the patient states a. "It will be several weeks before I can return to my usual activities." b. "I will avoid cooking with a microwave oven or being near one in use." c. "I will notify the airlines when I make a reservation that I have a pacemaker." d. "I won't lift the arm on the pacemaker side until I see the health care provider."

Answer: "I won't lift the arm on the pacemaker side until I see the health care provider." Rationale: The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period.

Which patient statement indicates that the nurse's teaching about carvedilol (Coreg) for preventing anginal episodes has been effective? a. "Carvedilol will help my heart muscle work harder." b. "It is important not to suddenly stop taking the carvedilol." c. "I can expect to feel short of breath when taking carvedilol." d. "Carvedilol will increase the blood flow to my heart muscle."

Answer: "It is important not to suddenly stop taking the carvedilol." Rationale: Patients who have been taking β-adrenergic blockers can develop intense and frequent angina if the medication is suddenly discontinued. Carvedilol (Coreg) decreases myocardial contractility. Shortness of breath that occurs when taking β-adrenergic blockers for angina may be due to bronchospasm and should be reported to the health care provider. Carvedilol works by decreasing myocardial O2 demand, not by increasing blood flow to the coronary arteries.

A patient who is diagnosed with Chlamydia tells the nurse that she is very angry because her husband is her only sexual partner. Which response should the nurse make first? a. "You may need professional counseling to help resolve your anger." b. "It is understandable that you feel angry about contracting an infection." c. "Your feelings are justified, and you should share them with your husband." d. "It is important that both you and your husband be treated for the infection."

Answer: "It is understandable that you feel angry about contracting an infection." Rationale: This response expresses the nurse's acceptance of the patient's feelings and encourages further discussion and problem solving. The patient may need professional counseling, but more assessment of the patient is needed before making this judgment. The nurse should also assess further before suggesting that the patient share her feelings with the husband because problems such as abuse might be present in the relationship. Although it is important that both partners be treated, the patient's anger suggests that the feelings need to be acknowledged first.

A female patient is diagnosed with Chlamydia during a routine pelvic examination. The nurse knows that teaching regarding the management of the condition has been effective when the patient says which of the following? a. "My partner will need to take antibiotics at the same time I do." b. "Go ahead and give me the antibiotic injection, so I will be cured." c. "I will use condoms during sex until I finish taking all the antibiotics." d. "I do not plan on having children, so treating the infection is not important."

Answer: "My partner will need to take antibiotics at the same time I do." Rationale: Sex partners should be treated simultaneously to prevent reinfection. Chlamydia is treated with oral antibiotics. Abstinence from sexual intercourse is recommended for 7 days after treatment. Condoms should be recommended during all sexual contacts to prevent infection. Chronic pelvic pain, as well as infertility, can result from untreated Chlamydia.

Which statement by a patient indicates good understanding of the nurse's teaching about preventing sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage opioids are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."

Answer: "Risk for a crisis is decreased by having an annual influenza vaccination." Rationale: Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.

A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML often goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress slowly." ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information.

Answer: "The side effects of chemotherapy are difficult, but AML often goes into remission with chemotherapy." Rationale: This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information.

A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is an option. Which response is accurate? a. "Your heart failure has not reached the end stage yet." b. "You could not manage the multiple complications of that surgery." c. "The suitability of a heart transplant for you depends on many factors." d. "Because you have diabetes, you would not be a heart transplant candidate."

Answer: "The suitability of a heart transplant for you depends on many factors." Rationale: Indications for a heart transplant include end-stage heart failure (stage D), but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Patients with diabetes who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, there are no data to suggest that the patient could not manage the care.

When a 31-yr-old male patient returns to the clinic for follow-up after treatment for gonococcal urethritis, a purulent urethral discharge is still present. Which question will the nurse ask to identify a possible cause of recurrent infection? a. "Did you take the prescribed antibiotic for a week?" b. "Did you drink at least 3 quarts of fluids every day?" c. "Were your sexual partners treated with antibiotics?" d. "Do you wash your hands after using the bathroom?"

Answer: "Were your sexual partners treated with antibiotics?" Rationale: A common reason for recurrence of symptoms is reinfection because infected partners have not been simultaneously treated. Because gonorrhea is treated with one dose of antibiotic, antibiotic therapy for a week is not needed. An adequate fluid intake is important, but a low fluid intake is not a likely cause for failed treatment. Poor hygiene may cause complications such as ocular trachoma but will not cause a failure of treatment.

After having 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? a. "What do you think caused your chest pain?" b. "Where are you planning to go for your vacation?" c. "Sometimes plans need to change after a heart attack." d. "Recovery from a heart attack takes at least a few weeks."

Answer: "What do you think caused your chest pain?" Rationale: When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient's plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.

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 (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin daily?" c. "What time did your pain begin?" d. "Can you rate the pain on a 0 to 10 scale?"

Answer: "What time did your pain begin?" Rationale: Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction, so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information is not a factor in the decision about thrombolytic therapy.

A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?

Answer: 21 Rationale: To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min.

A patient has a junctional escape rhythm on the monitor. What heart rate should the nurse expect the patient to have? a. 15 to 20 b. 20 to 40 c. 40 to 60 d. 60 to 100

Answer: 40 to 60 Rationale: If the sinoatrial (SA) node does not discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40 to 60 beats/min. The slower rates are typical of the bundle of His and Purkinje system and may be seen with failure of both the SA and AV node to discharge. The normal SA node rate is 60 to 100 beats/min.

When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ____.

Answer: 50 Rationale: There are 1500 small blocks in a minute, and the nurse will divide 1500 by 30.

After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first? a. A 39-year-old patient with pericarditis who is complaining of sharp, stabbing chest pain. b. A 56-year-old patient with variant angina who is scheduled to receive nifedipine (Procardia). c. A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge. d. A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI).

Answer: A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI). Rationale: After PCI, the patient is at risk for hemorrhage from the arterial access site. The nurse should assess the patient's blood pressure, pulses, and the access site immediately. The other patients should also be assessed as quickly as possible, but assessment of this patient has the highest priority.

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first? a. A patient who reported dizziness after receiving the first dose of captopril. b. A patient who has new-onset confusion and restlessness and cool, clammy skin. c. A patient who is receiving oxygen and has crackles bilaterally in the lung bases. NURSINGTB.COM d. A patient who is receiving IV nesiritide (Natrecor), with a blood pressure of 100/62.

Answer: A patient who has new-onset confusion and restlessness and cool, clammy skin. Rationale: The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible but do not have indications of severe decreases in tissue perfusion.

The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due b. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating c. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago d. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due

Answer: A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due Rationale: The frequent firing of the ICD indicates that the patient's ventricles are very irritable. The priority is to assess the patient and give the amiodarone. The other patients can be seen after the amiodarone is given.

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. A patient with chronic heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains

Answer: A patient with chronic heart failure Rationale: Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

Answer: Absolute neutrophil count Rationale: Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

The nurse is caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI). What should the nurse anticipate teaching the patient? a. Sudden cardiac death events rarely reoccur. b. Additional diagnostic testing will be required. c. Long-term anticoagulation therapy will be needed. d. Limiting physical activity will prevent future SCD events.

Answer: Additional diagnostic testing will be required. Rationale: Diagnostic testing (e.g., stress test, Holter monitor, electrophysiologic studies, cardiac catheterization) is used to determine the possible cause of the SCD and treatment options. SCD is likely to recur. Anticoagulation therapy will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting.

A 20-yr-old patient has a mandatory electrocardiogram (ECG) before participating on a college soccer team. The patient is found to have sinus bradycardia, rate 52 and blood pressure (BP) 114/54 mm Hg. The student denies any health problems. What action by the nurse is appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the student's family health history.

Answer: Allow the student to participate on the soccer team. Rationale: In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family's health history. Dyspnea during an aerobic activity such as soccer is normal.

Following an acute myocardial infarction, a previously healthy 63-yr-old develops heart failure. What medication topic should the nurse anticipate including in discharge teaching? a. β-Adrenergic blockers b. Calcium channel blockers c. Digitalis and potassium therapy regimen d. Angiotensin-converting enzyme (ACE) inhibitors

Answer: Angiotensin-converting enzyme (ACE) inhibitors Rationale: ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other drugs such as ACE-inhibitors, diuretics, and β-adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The β-adrenergic blockers are not used as initial therapy for new onset heart failure.

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching? a. Anticoagulant therapy b. Permanent pacemakers c. Emergency cardioversion d. IV adenosine (Adenocard)

Answer: Anticoagulant therapy Rationale: Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate.

A patient develops sinus bradycardia at a rate of 32 beats/min, has a blood pressure (BP) of 80/42 mm Hg, and reports feeling faint. Which action should the nurse take? a. Reposition the patient on the left side. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads.

Answer: Apply the transcutaneous pacemaker (TCP) pads. Rationale: The patient is experiencing symptomatic bradycardia and treatment with TCP is appropriate. Calcium channel blockers will further decrease the heart rate and the diltiazem should be held. The Valsalva maneuver will further decrease the rate. Repositioning on the left side may decrease cardiac output and blood pressure further.

Which action will the nurse take to evaluate the effectiveness of IV nitroglycerin for a patient with a myocardial infarction (MI)? a. Monitor heart rate. b. Ask about chest pain. c. Check blood pressure. d. Observe for dysrhythmias.

Answer: Ask about chest pain Rationale: The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse will also monitor heart rate and blood pressure and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

A 19-year-old student comes to the student health center at the end of the semester stating, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? a. Insert an IV catheter for emergency use. b. Start supplemental O2 at 2 to 3 L/min via nasal cannula. c. Ask the patient about current stress level and caffeine use. d. Have the patient taken to the nearest emergency department (ED).

Answer: Ask the patient about current stress level and caffeine use. Rationale: In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. The patient is hemodynamically stable, so there is no indication that the patient needs supplemental O2, an IV, or to be seen in the ED.

A patient who has had blood drawn for an insurance screening has a positive Rapid Plasma Reagin (RPR) test. Which action should the nurse take first? a. Ask the patient about past treatment for syphilis. b. Explain the need for blood and spinal fluid cultures. c. Schedule fluorescent treponemal antibody absorption (FTA-Abs) testing. d. Assess for the presence of chancres, flulike symptoms, or a rash on the trunk.

Answer: Ask the patient about past treatment for syphilis. Rationale: When antibody testing is positive for syphilis, the antibodies remain present for an indefinite period even after successful treatment, so the nurse should inquire about previous treatment before doing other assessments or testing. Culture, FTA-Abs testing, and assessment for symptoms may be appropriate based on whether the patient has been previously treated for syphilis.

Which assessment finding in a patient who has had coronary artery bypass grafting using a right radial artery graft is most important for the nurse to communicate to the health care provider? a. Complaints of incisional chest pain b. Pallor and weakness of the right hand c. Fine crackles heard at both lung bases d. Redness on both sides of the sternal incision

Answer: Pallor and weakness of the right hand Rationale: The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions, such as prescribed calcium channel blockers or surgery. The other changes are expected or require nursing interventions.

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-lb weight gain in the past 3 days. What is the nurse's priority action? a. Teach the patient about restricting dietary sodium. b. Assess the patient for manifestations of acute heart failure. c. Ask the patient about the use of the prescribed medications. d. Have the patient recall the dietary intake for the past 3 days.

Answer: Assess the patient for manifestations of acute heart failure. Rationale: The 5-lb weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

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? a. Attach the heart monitor. b. Obtain the blood pressure. c. Assess the peripheral pulses. d. Auscultate the breath sounds.

Answer: Attach the heart monitor. Rationale: Because dysrhythmias are the most common complication of myocardial infarction (MI), the first action should be to place the patient on a heart monitor. The other actions are also important and should be accomplished as quickly as possible.

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? a. Assess both feet for pedal edema. b. Palpate the radial pulses bilaterally. c. Auscultate for a pericardial friction rub. d. Check the heart monitor for dysrhythmias.

Answer: Auscultate for a pericardial friction rub. Rationale: The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient's symptoms.

A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse take first? a. Auscultate the abdomen. b. Check the capillary refill. c. Auscultate the breath sounds d. Ask about the patient's allergies.

Answer: Auscultate the breath sounds Rationale: This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) may be occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.

Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis? a. Limit fluids to 2 to 3 quarts per day. b. Avoid exposure to crowds when possible. c. Take a daily multivitamin supplement with iron. d. Drink no more than two caffeinated beverages daily.

Answer: Avoid exposure to crowds when possible. Rationale: Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

Answer: Avoid intramusucular (IM) injections Rationale: IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum troponin b. Arterial blood gases c. B-type natriuretic peptide d. 12-lead electrocardiogram

Answer: B-type natriuretic peptide Rationale: B-type natriuretic peptide (BNP) is secreted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probable or very probable diagnosis of heart failure. A 12-lead electrocardiogram, arterial blood gases, and troponin may also be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.

Which topic will the nurse plan to include in discharge teaching for a patient who has heart failure with reduced ejection fraction (HFrEF)? a. Need to begin an aerobic exercise program several times weekly b. Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors c. Use of salt substitutes to replace table salt when cooking and at the table d. Importance of making an annual appointment with the health care provider

Answer: Benefits and effects of angiotensin-converting enzyme (ACE) inhibitors Rationale: The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction below 40% should receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure. Salt substitutes are not usually recommended because of the risk of hyperkalemia. The patient will need to see the primary care provider more often than annually.

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Hyperglycemia b. Bilateral crackles c. Q waves on ECG d. Elevated troponin

Answer: Bilateral crackles Rationale: Pulmonary congestion suggests that the patient may be developing heart failure, a complication of myocardial infarction (MI). Hyperglycemia is common after MI because of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI.

IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. Which reassessment finding during the first hours of administration indicates that the nurse should decrease the rate of nitroprusside infusion? a. Ventricular ectopy b. Dry, hacking cough c. Systolic BP below 90 mm Hg d. Heart rate below 50 beats/min

Answer: Systolic BP below 90 mm Hg Rationale: Sodium nitroprusside is a potent vasodilator and the major adverse effect is severe hypotension. Coughing and bradycardia are not adverse effects of this medication. Nitroprusside does not cause increased ventricular ectopy.

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? a. The troponin level is elevated. b. The patient denies having a heart attack. c. Bilateral crackles in the mid-lower lobes. d. Occasional premature atrial contractions (PACs).

Answer: Bilateral crackles in the mid-lower lobes. Rationale: The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme inhibitors for the patient. Elevation in troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. Which laboratory value should the nurse monitor? a. Platelet count b. Bleeding time c. Thrombin time d. Prothrombin time

Answer: Bleeding time Rationale: The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.

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? a. 2+ bilateral pedal edema b. Heart rate of 52 beats/min c. Report of increased fatigue d. Blood pressure (BP) of 88/42 mm Hg

Answer: Blood pressure (BP) of 88/42 mm Hg Rationale: The patient's BP indicates that the dose of metoprolol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of β-adrenergic blockade, though it may need to be monitored. β-Adrenergic blockade initially will worsen symptoms of heart failure in many patients and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs.

Which data indicates to the nurse that the patient with stable angina is experiencing a side effect of metoprolol (Lopressor)? a. Patient is restless and agitated. b. Patient reports feeling anxious. c. Blood pressure is 90/54 mm Hg. d. Heart monitor shows normal sinus rhythm.

Answer: Blood pressure is 90/54 mmHg. Rationale: Patients taking β-adrenergic blockers should be monitored for hypotension and bradycardia. Because this class of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. Normal sinus rhythm is a normal and expected heart rhythm.

A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. What should the nurse plan to explain to the patient? a. Blood transfusion b. Bone marrow biopsy c. Filgrastim administration d. Erythropoietin administration

Answer: Bone marrow biopsy Rationale: Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary later if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/μL

Answer: Calf swelling and pain Rationale: The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.

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 is most specific for the nurse to monitor in determining whether the patient has had an AMI? a. Myoglobin b. Homocysteine c. C-reactive protein d. Cardiac-specific troponin

Answer: Cardiac-specific troponin Rationale: Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI) and are highly specific indicators for MI. Myoglobin is released within 2 hours of MI, but it lacks specificity and its use is limited. The other laboratory data are useful in determining the patient's risk for developing coronary artery disease but are not helpful in determining whether an acute MI is in progress.

Which action will the admitting nurse include in the care plan for a patient who has neutropenia? a. Avoid intramuscular injections. b. Check temperature every 4 hours. c. Place a "No Visitors" sign on the door. d. Omit fruits and vegetables from the diet.

Answer: Check temperature every 4 hours Rationale: The earliest sign of infection in a neutropenic patient is an elevation in temperature. While unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed.

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 patient problem is the priority? a. Anxiety b. Acute pain c. Stress management d. Decreased cardiac output

Answer: Decreased cardiac output Rationale: The hypotension and tachycardia indicate decreased cardiac output and shock from the damaged myocardium. This will result in decreased perfusion to all vital organs (e.g., brain, kidney, heart) and is a priority.

The nurse is administering a thrombolytic agent to a patient with an acute myocardial infarction. What patient data indicates that the nurse should stop the drug infusion? a. Bleeding from the gums b. An increase in blood pressure c. Decreased level of consciousness d. A nonsustained episode of ventricular tachycardia

Answer: Decreased level of consciousness Rationale: The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of thrombolytic therapy. Some bleeding of the gums is an expected side effect of the therapy but not an indication to stop infusion of the thrombolytic medication. A decrease in blood pressure could indicate internal bleeding. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

Diltiazem (Cardizem) is prescribed for a patient with newly diagnosed Prinzmetal's (variant) angina. Which action of diltiazem is accurate for the nurse to include in the teaching plan? a. Reduces heart palpitations. b. Prevents coronary artery plaque. c. Decreases coronary artery spasms. d. Increases contractile force of the heart.

Answer: Decreases coronary artery spasms Rationale: Prinzmetal's angina is caused by coronary artery spasm. Calcium channel blockers (e.g., diltiazem, amlodipine [Norvasc]) are a first-line therapy for this type of angina. Lipid-lowering drugs help reduce atherosclerosis (i.e., plaque formation), and β-adrenergic blockers decrease sympathetic stimulation of the heart (i.e., palpitations). Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing O2 demand.

To improve the physical activity level for a mildly obese 68-year-old patient, which action should the nurse plan to take? a. Stress that weight loss is a major benefit of increased exercise. b. Determine what kind of physical activities the patient usually enjoys. c. Tell the patient that older adults should exercise for no more than 20 minutes at a time. d. Teach the patient to include a short warm-up period at the beginning of physical activity.

Answer: Determine what kind of physical activities the patient usually enjoys. Rationale: Because patients are more likely to continue physical activities that they already enjoy, the nurse will plan to ask the patient about preferred activities. The goal for older adults is 30 minutes of moderate activity on most days. Older adults should plan for a longer warm-up period. Benefits of exercises, such as improved activity tolerance, should be emphasized rather than aiming for significant weight loss in older mildly obese adults.

The nurse reviews information shown in the accompanying figure from the medical records of a 43-year-old patient. Which risk factor modification for coronary artery disease should the nurse include in patient teaching? [CHART QUESTION, Chapter 33 question #41] a. Importance of daily physical activity b. Effect of weight loss on blood pressure c. Dietary changes to improve lipid levels d. Cardiac risk associated with previous tobacco use

Answer: Dietary changes to improve lipid levels Rationale: The patient has an elevated low-density lipoprotein cholesterol and low high-density lipoprotein cholesterol, which will increase the risk of coronary artery disease. The patient's waist circumference and body mass index indicate an appropriate body weight. The risk for coronary artery disease a year after quitting smoking is the same as a nonsmoker. The patient's occupation indicates that daily activity is at the levels suggested by national guidelines.

A 19-yr-old patient has genital warts around her external genitalia and perianal area. She tells the nurse that she has not sought treatment until now because "the warts are so disgusting." Which patient problem is consistent with these data? a. Anxiety b. Difficulty coping c. Lack of knowledge d. Disturbed body image

Answer: Disturbed body image Rationale: The patient's statement that her lesions are disgusting suggests that disturbed body image is the major concern. There is no evidence to indicate anxiety, difficulty coping, or lack of knowledge about mode of transmission.

A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval is 0.24 seconds. What action should the nurse take? a. Notify the health care provider immediately. b. Document the finding and monitor the patient. c. Give atropine per agency dysrhythmia protocol. d. Prepare the patient for temporary pacemaker insertion.

Answer: Document the finding and monitor the patient. Rationale: First-degree atrioventricular block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary.

A patient who has chest pain is admitted to the emergency department (ED), and all of the following items are prescribed. Which one should the nurse arrange to be completed first? a. Chest x-ray b. Troponin level c. Electrocardiogram (ECG) d. Insertion of a peripheral IV

Answer: Electrocardiogram ( ECG) Rationale: The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that the appropriate therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion, and an ECG should be obtained as soon as possible. Troponin levels will increase after about 3 hours. Data from the chest x-ray may impact the patient's care but are not helpful in determining whether the patient is experiencing a myocardial infarction. Peripheral access will be needed but not before the ECG.

The nurse is developing a teaching plan for a 64-year-old patient with coronary artery disease (CAD). Which factor should the nurse focus on during the teaching session? a. Family history of coronary artery disease b. Elevated low-density lipoprotein (LDL) level c. Greater risk associated with the patient's gender d. Increased risk of cardiovascular disease with aging

Answer: Elevated low-density lipoprotein (LDL) level Rationale: Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient's LDL level. Decreases in LDL will help reduce the patient's risk for developing CAD.

Which is an appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia? a. Provide a diet high in vitamin K. b. Teach the patient how to avoid injury. c. Encourage alternating rest and activity. d. Place the patient on protective isolation.

Answer: Encourage alternating rest and activity. Rationale: Nursing care for patients with anemia should alternate periods of rest and activity to avoid undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.

Which action should the nurse include in the plan of care for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? a. Monitor blood pressure frequently. b. Encourage patient to ambulate in room. c. Teach patient to drink at least 3 liters of fluid daily. d. Titrate nesiritide dose down slowly before stopping.

Answer: Encourage patient to ambulate in room. Rationale: Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Because the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration. Excessive hydration could exacerbate ADHF.

Which nursing intervention is important when providing care for a patient with sickle cell crisis? a. Limiting the patient's intake of oral and IV fluids b. Evaluating the effectiveness of opioid analgesics c. Encouraging the patient to ambulate as much as tolerated d. Teaching the patient about high-protein, high-calorie foods .

Answer: Evaluating the effectiveness of opioid analgesics Rationale: Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. Which nutrient supplement should the nurse plan to explain to the patient? a. Iron b. Folic acid c. Cobalamin (vitamin B12) d. Ascorbic acid (vitamin C)

Answer: Folic acid Rationale; Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to the nurse. Which information is most important to communicate to the health care provider? a. Generalized muscle aches and pains b. Dizziness with rapid position changes c. Nausea when taking the drugs before meals d. Flushing and pruritus after taking the drugs

Answer: Generalized muscle aches and pains Rationale: Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the pravastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow-up with the health care provider, they do not indicate that a change in medication is needed.

A patient in the intensive care unit who has acute decompensated heart failure (ADHF) reports severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been prescribed for the patient. Which action should the nurse take first? a. Give PRN IV morphine sulfate 4 mg. b. Give PRN IV diazepam (Valium) 2.5 mg. c. Increase nitroglycerin infusion by 5 mcg/min. d. Increase dopamine infusion by 2 mcg/kg/min.

Answer: Give PRN IV morphine sulfate 4 mg. Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea.

A patient with supraventricular tachycardia who is alert and has a blood pressure of 110/66 mm Hg is being prepared for cardioversion. Which action should the nurse take? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.

Answer: Give a sedative before cardioversion is implemented. Rationale: When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient.

A patient on the telemetry unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the agency dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patient's blood pressure and discomfort level.

Answer: Give supplemental O2 at 2 to 3 L/min via nasal cannula. Rationale: Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by starting with O2 administration. The other actions are also important and should be implemented rapidly.

A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when scheduling this medication? a. Administer the medication at the patient's usual bedtime. b. Have the patient take the colesevelam 1 hour before breakfast. c. Give the patient's other medications 2 hours after colesevelam. d. Have the patient take the dose at the same time as the prescribed aspirin.

Answer: Give the patient's other medications 2 hours after colesevelam. Rationale: The bile acid sequestrants interfere with the absorption of many other drugs and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. For maximum effect, colesevelam should be administered with meals.

The nurse is caring for a patient who has just arrived on the telemetry unit after having cardiac catheterization. What task should the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? a. Teach the patient about the postprocedure plan of care. b. Give the scheduled aspirin and lipid-lowering medication. c. Perform the initial assessment of the catheter insertion site. d. Titrate the heparin infusion according to the agency protocol.

Answer: Give the scheduled aspirin and lipid-lowering medication. Rationale: Administration of oral medications is within the scope of practice for LPNs/VNs. The initial assessment of the patient, patient teaching, and titration of IV anticoagulant medications should be done by the registered nurse (RN).

A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest? a. O2 saturation drops from 99% to 95%. b. Heart rate increases from 66 to 98 beats/min. c. Respiratory rate goes from 14 to 20 breaths/min. d. Blood pressure (BP) changes from 118/60 to 126/68 mm Hg.

Answer: Heart rate increases from 66 to 98 beats/min Rationale: A change in heart rate of more than 20 beats over the resting heart rate indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in O2 saturation, are normal responses to exercise.

Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes? a. Inform the patient about a diet containing no saturated fat and minimal salt. b. Emphasize the increased cardiac risk unless the patient makes dietary changes. c. Help the patient modify favorite high-fat recipes by using monounsaturated oils. d. Give the patient a list of low-sodium, low-cholesterol foods to include in the diet.

Answer: Help the patient modify favorite high-fat recipes by using monounsaturated oils. Rationale: Lifestyle changes are more likely to be successful when consideration is given to the patient's values and preferences. The highest percentage of calories from fat should come from monounsaturated or polyunsaturated fats. Although low-sodium and low-cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Completely removing saturated fat from the diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

An adult male with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms? a. RBC count of 4,500,000/μL b. Hematocrit (Hct) value of 38% c. Normal red blood cell (RBC) indices d. Hemoglobin (Hgb) of 8.6 g/dL (86 g/L)

Answer: Hemoglobin (Hgb) of 8.6 g/dL (86 g/L) Rationale: The patient's symptoms indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.

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 first? a. Place the transcutaneous pacemaker pads on the patient. b. Give atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Hold the scheduled metoprolol (Lopressor) and call the health care provider. d. Document the patient's rhythm and PR measurements in the medical record.

Answer: Hold the scheduled metoprolol (Lopressor) and call the health care provider. Rationale: The patient has progressive first-degree atrioventricular (AV) block, and the β-blocker should be held until discussing the drug with the health care provider. Documentation is appropriate later. The patient with first-degree AV block usually is asymptomatic; if the patient became symptomatic, a pacemaker or atropine may be used.

A patient has ST segment changes that suggest an acute inferior wall myocardial infarction. Which lead would be the most useful for monitoring the patient? a. I b. II c. V2 d. V6

Answer: II Rationale: Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area.

The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. Which action should the nurse take? a. Apply heat to the knee. b. Immobilize the knee joint. c. Assist the patient with light weight bearing. d. Perform passive range of motion to the knee.

Answer: Immobilize the knee joint Rationale: The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree NURSINGTB.COM atrioventricular (AV) block, which finding indicates that the drug has been effective? a. Increase in the patient's heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions

Answer: Increase in the patient's heart rate Rationale: Atropine will increase the heart rate and conduction through the AV node. Because the drug increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions.

While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate? a. Decreased fluid volume b. Jugular vein atherosclerosis c. Increased right atrial pressure d. Incompetent jugular vein valves

Answer: Increased right atrial pressure Rationale: The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.

Which potential complication should the nurse identify as a high risk for a patient admitted to the hospital with idiopathic aplastic anemia? a. Seizures b. Infection c. Neurogenic shock d. Pulmonary edema

Answer: Infection Rationale: Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.

Answer: Infuse normal saline 500 mL over 30 minutes. Rationale: The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.

A patient with gonorrhea is treated with a single IM dose of ceftriaxone and is given a prescription for azithromycin (Zithromax) 1000 mg × 1 dose. What rationale should the nurse provide to the patient for this combination? a. Prevent reinfection during treatment. b. Treat any coexisting syphilis infection. c. Provides coverage for possible chlamydia infection. d. Provides coverage for possible trichomonas infection.

Answer: Provides coverage for possible chlamydia infection. Rationale: Because there is a high incidence of co-infection with gonorrhea and Chlamydia, patients are usually treated for both. The other explanations about the purpose of the antibiotic combination are not accurate.

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? a. Prepares defibrillator settings at 360 joules for a patient whose monitor shows asystole. b. Injects IV adenosine (Adenocard) over 2 seconds for a patient with supraventricular tachycardia. c. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation. d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second-degree AV block.

Answer: Injects IV adenosine (Adenocard) over 2 seconds for a patient with supraventricular tachycardia. Rationale: Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more teaching about treatment of heart dysrhythmias. The RN should hold the diltiazem until discussing it with the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating.

A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). What is the best approach for the nurse to assist the patient with this treatment decision? a. Discuss the need for insurance to cover post-HSCT care. b. Inquire whether there are questions or concerns about HSCT. c. Emphasize the positive outcomes of a bone marrow transplant. d. Explain that a cure is not possible with any treatment except HSCT.

Answer: Inquire whether there are questions or concerns about HSCT. Rationale: Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a. Explain the association between dysrhythmias and syncope. b. Instruct the patient to call for assistance before getting out of bed. c. Teach the patient about the need to avoid caffeine and other stimulants. d. Tell the patient about the benefits of implantable cardioverter-defibrillators.

Answer: Instruct the patient to call for assistance before getting out of bed. Rationale: A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient is up. The other actions may be needed if dysrhythmias are found to be the cause of the patient's syncope but are not appropriate for syncope of unknown origin.

A patient is diagnosed with primary syphilis during her eighth week of pregnancy. What information should the nurse discuss with the patient? a. Likelihood of a stillbirth b. Plans for cesarean section c. Intramuscular injection of penicillin d. Antibiotic eyedrops for the newborn

Answer: Intramuscular injection of penicillin Rationale: A single injection of penicillin is recommended to treat primary syphilis. This will treat the mother and prevent transmission of the disease to the fetus. Instillation of erythromycin into the eyes of the newborn is used to prevent gonorrheal eye infections. C-section is used to prevent the transmission of herpes to the newborn. Although stillbirth can occur if the fetus is infected with syphilis, treatment before the 10th week of gestation will eliminate in utero transmission to the fetus.

What action is expected by the nurse caring for a patient who has an acute exacerbation of polycythemia vera? a. Place the patient on bed rest. b. Administer iron supplements. c. Avoid use of aspirin products. d. Monitor fluid intake and output.

Answer: Monitor fluid intake and output. Rationale: Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis. Iron is contraindicated in patients with polycythemia vera.

A patient who is receiving dobutamine for the treatment of acute decompensated heart failure (ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)? a. Teach the patient the reasons for remaining on bed rest. b. Change the peripheral IV site according to agency policy. c. Monitor the patient's blood pressure and heart rate every hour. d. Titrate the dobutamine to keep the systolic blood pressure >90 mm Hg.

Answer: Monitor the patient's blood pressure and heart rate every hour. Rationale: An experienced LPN/VN would be able to monitor BP and heart rate and would know to report significant changes to the RN. Teaching patients, adjusting the drip rate for vasoactive drugs, and inserting a new peripheral IV catheter require RN level education and scope of practice.

Which infection reported in the health history of a female patient will the nurse identify as a risk factor for infertility? a. Treponema pallidum b. Neisseria gonorrhoeae c. Condyloma acuminatum d. Herpes simplex virus type 2

Answer: Neisseria gonorrhoeae Rationale: Complications of gonorrhea include scarring of the fallopian tubes, which can lead to tubal pregnancies and infertility. Syphilis, genital warts, and genital herpes do not lead to problems with conceiving, although transmission to the fetus (syphilis) or newborn (genital warts or genital herpes) is a concern.

The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? History Physical Assessment Laboratory Results • Fatigue, which has increased over last month • Frequent constipation • Conjunctiva pale pink, moist • Multiple bruises • Clear lung sounds • Hct 33% • WBC 1500/µL • Platelets 70,000/µL a. Bruising b. Neutropenia c. Increasing fatigue d. Thrombocytopenia

Answer: Neutropenia Rationale: The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leukopenia. The other information may require further assessment or treatment but does not place the patient at immediate risk for complications.

What should the nurse measure to determine whether there is a delay in impulse conduction through the patient's ventricles? a. P wave b. Q wave c. PR interval d. QRS complex

Answer: QRS complex Rationale: The QRS complex represents ventricular depolarization. The P wave represents the depolarization of the atria. The PR interval represents depolarization of the atria, atrioventricular node, bundle of His, bundle branches, and the Purkinje fibers. The Q wave is the first negative deflection following the P wave and should be narrow and short.

Which information about a patient receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider? a. An increase in troponin levels from baseline b. A large bruise at the patient's IV insertion site c. No change in the patient's reported level of chest pain d. A decrease in ST-segment elevation on the electrocardiogram

Answer: No change in the patient's reported level of chest pain Rationale: Continued chest pain suggests that the thrombolytic therapy is not effective and that other interventions such as percutaneous coronary intervention may be needed. Bruising is a possible side effect of thrombolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST-segment elevation indicates that thrombolysis is occurring, and perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the washout of cardiac biomarkers into the circulation as the blocked vessel is opened.

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid other venipunctures. b. Apply dressings to the sites. c. Notify the health care provider. d. Give prescribed proton-pump inhibitors. The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly.

Answer: Notify the health care provider Rationale: The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly.

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Which instruction should the nurse include? a. Limit dietary sources of potassium. b. Take the hydrochlorothiazide at bedtime. c. Notify the health care provider if nausea develops. d. Take the digoxin if the pulse is below 60 beats/min.

Answer: Notify the health care provider if nausea develops. Rationale: Nausea is a symptom of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60 beats/min, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? a. O2 saturation of 88% b. Weight gain of 1 kg (2.2 lb) c. Heart rate of 106 beats/min d. Urine output of 50 mL over 2 hours

Answer: O2 saturation of 88% Rationale: A decrease in O2 saturation to less than 92% indicates hypoxemia, and the nurse should start supplemental O2 immediately. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output may also indicate worsening heart failure and require nursing actions, but the low O2 saturation rate requires the most immediate nursing action.

Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as telemetry technicians on the cardiac care unit? a. Decide whether a patient's heart rate of 116 requires urgent treatment. b. Observe heart rhythms for multiple patients who have telemetry monitoring. c. Monitor a patient's level of consciousness during synchronized cardioversion. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome.

Answer: Observe heart rhythms for multiple patients who have telemetry monitoring. Rationale: UAP serving as telemetry technicians can monitor heart rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice.

A patient in the sexually transmitted infection (STI) clinic tells the nurse that she is concerned she may have been exposed to gonorrhea. How will the nurse plan to determine whether the patient has gonorrhea? a. Interview the patient about symptoms of gonorrhea. b. Take a sample of cervical discharge for Gram staining. c. Draw a blood specimen for rapid plasma reagin (RPR) testing. d. Obtain secretions for a nucleic acid amplification test (NAAT). ANS: D

Answer: Obtain secretions for a nucleic acid amplification test (NAAT). Rationale: NAAT has a high sensitivity (similar to a culture) for gonorrhea. Because women have few symptoms of gonorrhea, asking the patient about symptoms may not be helpful in making a diagnosis. Smears and Gram staining are not useful because the female genitourinary tract has many normal flora that resemble N. gonorrhoeae. RPR testing is used to detect syphilis.

A patient who reports a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? a. Prepare to perform electrical cardioversion. b. Have the patient perform the Valsalva maneuver. c.Obtain the patient's vital signs including O2 saturation. d. Prepare to give a β-blocker medication to slow the heart rate.

Answer: Obtain the patient's vital signs including O2 saturation. Rationale: The patient has sinus tachycardia, which may have multiple causes, such as pain, dehydration, anxiety, and myocardial ischemia. Further assessment is needed before determining the treatment. Vagal stimulation or β-blockade may be used after further assessment of the patient. Electrical cardioversion is a treatment for some tachydysrhythmias but not sinus tachycardia.

Which menu choice indicates that the patient understands the nurse's recommendations about dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

Answer: Omelet and whole wheat toast Rationale: Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but Iwoke up in the middle of the night feeling like I was suffocating!" How should the nurse document this finding? a. Orthopnea b. Pulsus alternans c. Paroxysmal nocturnal dyspnea d. Acute bilateral pleural effusion

Answer: Paroxysmal nocturnal dyspnea Rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alteration of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a long period of time.

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. What data would indicate to the nurse that the drug is effective? a. Decreased blood pressure and heart rate b. Improvement in the strength of the distal pulses c. Fewer complaints of having cold hands and feet d. Participation in daily activities without chest pain

Answer: Participation in daily activities without chest pain Rationale: Because the drug is ordered to improve the patient's angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective β-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first? a. Patient who is taking carvedilol (Coreg) and has a heart rate of 58. b. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L. c. Patient who is taking captopril and has a frequent nonproductive cough. d. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache.

Answer: Patient who is taking digoxin and has a potassium level of 3.1 mEq/L. Rationale: The patient's low potassium level increases the risk for digoxin toxicity and potentially life-threatening dysrhythmias. The nurse should assess the patient for other signs of digoxin toxicity and then notify the health care provider about the potassium level. The other patients also have side effects of their drugs, but their symptoms do not indicate potentially life-threatening complications.

Which patient at the cardiovascular clinic requires the most immediate action by the nurse? a. Patient with type 2 diabetes whose current blood glucose level is 145 mg/dL. b. Patient with stable angina whose chest pain has recently increased in frequency. c. Patient with familial hypercholesterolemia and a total cholesterol of 465 mg/dL. d. Patient with chronic hypertension whose blood pressure today is 172/98 mm Hg.

Answer: Patient with stable angina whose chest pain has recently increased in frequency. Rationale: The history of more frequent chest pain suggests that the patient may have unstable angina, which is part of the acute coronary syndrome spectrum. This will require rapid implementation of actions such as cardiac catheterization and possible percutaneous coronary intervention. The data about the other patients suggest that their conditions are more stable.

A patient with acute coronary syndrome has returned to the coronary care unit after having angioplasty with stent placement. Which assessment data indicate the need for immediate action by the nurse? a. Report of chest pain b. Heart rate 102 beats/min c. Pedal pulses 1+ bilaterally d. Blood pressure 103/54 mm Hg

Answer: Pedal pulses 1+ bilaterally Rationale: The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.

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? a. Give epinephrine (Adrenalin) IV. b. Perform immediate defibrillation. c. Prepare for endotracheal intubation. d. Ventilate with a bag-valve-mask device.

Answer: Perform immediate defibrillation. Rationale: The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, begin chest compressions. The other actions may also be appropriate but not first.

A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. Platelet count is 42,000/μL. b. Blood pressure is 94/56 mm Hg. c. Petechiae are present on the chest. d. Blood is oozing from the venipuncture site.

Answer: Platelet count is 42,000/μL. Rationale: Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/μL unless the patient is actively bleeding. Therefore, the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.

A patient who was admitted with a myocardial infarction has a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Prepare for synchronized cardioversion per agency protocol. d. Prepare to give IV amiodarone per agency dysrhythmia protocol.

Answer: Prepare to give IV amiodarone per agency dysrhythmia protocol. Rationale: The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Cardioversion is not indicated given that the patient has returned to a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.

A patient with diabetes mellitus and chronic stable angina has a new order for captopril. What should the nurse teach this patient about the primary purpose of captopril? a. Decreases the heart rate. b. Controls blood glucose levels. c. Prevents changes in heart muscle. d. Reduces the frequency of chest pain.

Answer: Prevents changes in heart muscle. Rationale: The purpose for angiotensin-converting enzyme (ACE) inhibitors in patients with chronic stable angina who are at high risk for a cardiac event is to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate.

A male patient who has a profuse, purulent urethral discharge with painful urination is seen at the clinic. Which information should the nurse obtain as a basis for planning focused care? a. Sexual orientation b. Immunization history c. Recent sexual contacts d. Contraceptive preference

Answer: Recent sexual contacts Rationale: Information about sexual contacts is needed to help establish whether the patient has been exposed to a sexually transmitted infection and because sexual contacts also will need treatment. The other information is not pertinent in determining the plan of care for the patient's current symptoms.

The nurse is caring for a patient who is receiving IV furosemide (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 has been effective? a. Weight loss of 2 lb in 24 hours b. Hourly urine output greater than 60 mL c. Reduced dyspnea with the head of bed at 30 degrees d. Patient denies experiencing chest pain or chest pressure

Answer: Reduced dyspnea with the head of bed at 30 degrees Rationale: Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data may also indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patient's response.

While admitting an 82-yr-old patient 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." What should the nurse include in the discharge plan? a. Consult with a psychologist. b. Transfer to a long-term care facility. c. Referral to a home health care agency. d. Arrangements for around-the-clock care.

Answer: Referral to a home health care agency. Rationale: The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as a psychologist consult, long-term care, or around-the-clock home care.

A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/VN)? a. Reinforcement of teaching about the prescribed medications b. Evaluation of the patient's response to walking in the hallway c. Completion of the referral form for a home health nurse follow-up d. Education of the patient about the pathophysiology of heart disease

Answer: Reinforcement of teaching about the prescribed medications Rationale: LPN/VN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient's response to exercise after a NSTEMI requires more education and should be done by the RN. Teaching and discharge planning and referral are skills that require RN education and scope of practice.

Which electrocardiographic (ECG) change by a patient with chest pain is most important for the nurse to report rapidly to the health care provider? a. Inverted P wave b. Sinus tachycardia c. ST-segment elevation d. First-degree atrioventricular block

Answer: ST-segment elevation Rationale: The patient is likely to be experiencing an ST-segment-elevation myocardial infarction. Immediate therapy with percutaneous coronary intervention or thrombolytic medication is indicated to minimize myocardial damage. The other ECG changes may also suggest a need for therapy but not as rapidly.

A patient who has heart failure has recently started taking digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1+ to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days

Answer: Serum potassium level 3.0 mEq/L after 1 week of therapy Rationale: Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions) and potentiate the actions of digoxin. Hypokalemia also increases the risk for digoxin toxicity, which can also cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.

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? a. Blood glucose of 243 mg/dL b. Serum chloride of 92 mEq/L c. Serum sodium of 134 mEq/L d. Serum potassium of 2.9 mEq/L

Answer: Serum potassium of 2.9 mEq/L Rationale: Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values are also abnormal, they are not likely to be the cause of the patient's PVCs and do not require immediate correction.

A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about safely resuming sexual intercourse. Which response by the nurse is best? a. "Most patients are able to enjoy intercourse without any complications." b. "Sexual activity uses about as much energy as climbing two flights of stairs." c. "The doctor will provide sexual guidelines when your heart is strong enough." d. "Holding and cuddling are good ways to maintain intimacy after a heart attack."

Answer: Sexual activity uses about as much energy as climbing two flights of stairs." Rationale: Sexual activity places about as much physical stress on the cardiovascular system as moderate-energy activities, such as climbing two flights of stairs. The other responses are general statements that may be accurate, but do not provide useful guidelines for judging the physical safety of the activity.

A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Give atropine per agency dysrhythmia protocol. d. Apply supplemental O2 via non-rebreather mask.

Answer: Start cardiopulmonary resuscitation (CPR). Rationale: The patient's manifestations indicate pulseless electrical activity, and the nurse should immediately start CPR. The other actions would not be of benefit to this patient.

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? a. Tadalafil (Cialas) b. Furosemide (Lasix) c. Warfarin (Coumadin) d. Diltiazem (Cardizem)

Answer: Tadalafil (Cialas) Rationale: The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using tadalafil because of the risk of severe hypotension caused by vasodilation. The other home medications should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient's treatment.

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums

Answer: Tarry stools Rationale: Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss.

A 20-yr-old female patient who is being seen in the family medicine clinic for an annual physical examination reports being sexually active. What topic should the nurse plan to teach the patient? a. Testing for Chlamydia infection b. Immunization for herpes simplex c. Infertility associated with the human papillomavirus (HPV) d. The relationship between the herpes virus and cervical cancer

Answer: Testing for Chlamydia infection Rationale: The Centers for Disease Control and Prevention recommends testing for Chlamydia for all sexually active women younger than age 25 years. HPV infection does not cause infertility. There is no vaccine available for herpes simplex, and herpes simplex infection does not cause cervical cancer.

Which action by a nurse caring for a patient after an implantable cardioverter-defibrillator (ICD) insertion indicates a need for more teaching about the care of patients with ICDs? a. The nurse administers amiodarone (Cordarone) to the patient. b. The nurse helps the patient fill out the application for obtaining a Medic Alert device. c. The nurse encourages the patient to do active range-of-motion exercises for all extremities. d. The nurse teaches the patient that sexual activity can be resumed when the incision is healed.

Answer: The nurse encourages the patient to do active range-of-motion exercises for all extremities. Rationale: The patient should avoid moving the arm on the ICD insertion site until healing has occurred to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is from an acute myocardial infarction? a. The pain increases with deep breathing. b. The pain has lasted longer than 30 minutes. c. The pain is relieved after the patient takes nitroglycerin. d. The pain is reproducible when the patient raises the arms.

Answer: The pain has lasted longer than 30 minutes. Rationale: Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of musculoskeletal pain or pericarditis. Stable angina is usually relieved when the patient takes nitroglycerin.

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? a. Bruises on the patient's back. b. The patient is difficult to arouse. c. Purpura on the patient's oral mucosa. d. The patient's platelet count is 52,000/µL.

Answer: The patient is difficult to arouse Rationale: Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.

Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain. b. The patient with neutropenia who has a temperature of 101.8° F. c. The patient with thrombocytopenia who has oozing gums after a tooth extraction. d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours.

Answer: The patient with neutropenia who has a temperature of 101.8° F. Rationale: A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

Which information will the nurse include when teaching a patient with atrial flutter who is scheduled for a radiofrequency catheter ablation? a. The procedure stimulates the growth of new pathways between the atria. b. The procedure uses cold therapy to stop the formation of the flutter waves. c. The procedure uses electrical energy to destroy areas of the conduction system. d. The procedure prevents or minimizes the patient's risk for sudden cardiac death.

Answer: The procedure uses electrical energy to destroy areas of the conduction system. Rationale: Radiofrequency catheter ablation therapy uses electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements about the procedure are incorrect.

A patient reports dizziness and shortness of breath for several days. During heart monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. How does the nurse interpret this heart rhythm? [CHART QUESTION, CHAPTER 35, Question 28] a. Junctional escape rhythm b. Accelerated idioventricular rhythm c. Third-degree atrioventricular (AV) block d. Sinus rhythm with premature atrial contractions

Answer: Third-degree atrioventricular (AV) block Rationale: The inconsistency between the atrial and ventricular rates and the variable PR interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent PR intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves.

A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? a. Infuse PRBCs slowly over 4 hours. b. Transfuse leukocyte-reduced PRBCs. c. Administer the prescribed diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion. ANS: B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.

Answer: Transfuse leukocyte-reduced PRBCs. Rationale: TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.

The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be fastest to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. d. Calculate the number of small squares between one QRS complex and the next and divide into 1500.

Answer: Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. Rationale: Using the 3-second markers to count the number of QRS complexes in 6 seconds and multiplying by 10 is the quickest way to determine the ventricular rate for a patient with a regular rhythm. The other methods are accurate but take longer.

A patient's heart monitor shows that every other beat is earlier than expected, has no visible wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions

Answer: Ventricular bigeminy Rationale: Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions are multifocal or that the R-on-T phenomenon is occurring.

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, QRS complex wide and distorted, and QRS duration of 0.18 second. How should the nurse interpret this cardiac rhythm? a. Atrial flutter b. Sinus tachycardia c. Ventricular fibrillation d. Ventricular tachycardia

Answer: Ventricular tachycardia Rationale: The absence of P waves, wide QRS, rate greater than 150 beats/min, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration.

A patient admitted with chest pain is found to have positive rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption (FTA-Abs) tests, rashes on the palms and the soles of the feet, and moist papules in the anal and vulvar area. Which action will the nurse include in the plan of care? a. Assess for arterial aneurysms. b. Wear gloves for patient contact. c. Place the patient in a private room. d. Apply antibiotic ointment to the perineum.

Answer: Wear gloves for patient contact. Rationale: Exudate from any lesions with syphilis is highly contagious. Systemic antibiotics, rather than local treatment of lesions, are used to treat syphilis. The patient does not require a private room because the disease is spread through contact with the lesions. This patient has clinical manifestations of secondary syphilis and does not need to be monitored for manifestations of tertiary syphilis.

. The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. What should teaching for this patient include today? a. Typical emotional responses to AMI b. When cardiac rehabilitation will begin c. Pathophysiology of coronary artery disease d. Information regarding discharge medications

Answer: When cardiac rehabilitation will begin Rationale: Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient's anxiety level or denial will interfere with good understanding of complex information such as the pathophysiology of coronary artery disease. Teaching about discharge medications should be done closer to discharge. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional responses to myocardial infarction.

A male patient who has been diagnosed with gonococcal urethritis tells the nurse he had recent sexual contact with a woman but says she did not appear to have any disease. What information should the nurse explain to the patient? a. Women develop subclinical cases of gonorrhea that are not true gonorrheal infections. b. Women do not develop gonorrhea infections but can serve as carriers to spread the disease to men. c. Women may not be aware they have gonorrhea because they often do not have symptoms of infection. d. When gonorrhea infections occur in women, the disease affects only the ovaries and not the genital organs.

Answer: Women may not be aware they have gonorrhea because they often do not have symptoms of infection. Rationale: Many women with gonorrhea are asymptomatic or have minor symptoms that are overlooked. The disease may affect both the genitals and the other reproductive organs and cause complications such as pelvic inflammatory disease. Women who can transmit the disease have active infections, not subclinical cases or carrier status.

When teaching a patient with heart failure on a 2000-mg sodium diet, which foods should the nurse recommend limiting? a. Chicken and eggs b. Canned and frozen fruits c. Yogurt and milk products d. Fresh or frozen vegetables

Answer: Yogurt and milk products Rationale: Yogurt and milk products (e.g., cheese) naturally contain a significant amount of sodium, and the intake of these should be limited for patients on a diet that limits sodium to 2000 mg daily. The other foods listed have minimal levels of sodium and can be eaten without restriction.

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? a. captopril (Capoten) 25 mg b. furosemide (Lasix) 60 mg c. digoxin (Lanoxin) 0.125 mg d. carvedilol (Coreg) 3.125 mg

Answer: carvedilol (Coreg) 3.125 mg Rationale: Although carvedilol is appropriate for the treatment of chronic heart failure, it is not used for patients with acute decompensated heart failure (ADHF) because of the risk of worsening the heart failure. The other drugs are appropriate for the patient with ADHF.

A 39-yr-old patient with a history of IV drug use is seen at a community clinic. The patient reports difficulty walking, stating, "I don't know where my feet are." Diagnostic screening reveals positive rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption (FTA-Abs) test results. Based on the patient history, what will the nurse assess? (Select all that apply.) a. Heart sounds b. Genitalia for lesions c. Joints for swelling and inflammation d. Mental state for judgment and orientation e. Skin and mucous membranes for gummas

Answers: a. Heart sounds d. Mental state for judgment and orientation e. Skin and mucous membranes for gummas Rationale: The patient's clinical manifestations and laboratory tests are consistent with tertiary syphilis. Valvular insufficiency, gummas, and changes in mentation are other clinical manifestations of this stage.

Which topics will the nurse include when preparing to teach a patient with recurrent genital herpes simplex? (Select all that apply.) a. Infected areas should be kept moist to speed healing. b. Sitz baths may be used to relieve discomfort caused by the lesions. c. Consistent use of antiviral medications can cure genital herpes infection. d. Recurrent genital herpes episodes usually are shorter than the first episode. e. The virus can infect sexual partners even when you do not have symptoms.

Answers: b. Sitz baths may be used to relieve discomfort caused by the lesions. d. Recurrent genital herpes episodes usually are shorter than the first episode. e. The virus can infect sexual partners even when you do not have symptoms. Rationale: Patients are taught that shedding of the virus and infection of sexual partners can occur even in asymptomatic periods, recurrent episodes resolve more quickly, and sitz baths can be used to relieve pain caused by the lesions. Antiviral medications decrease the number of outbreaks but do not cure herpes simplex infections. Infected areas may be kept dry if this decreases pain and itching.

When preparing to defibrillate a patient, in which order will the nurse perform the following steps? a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the hands-free, multifunction defibrillator pads on the patient's chest. e. Check the location of other staff and call out "all clear." This order will result in rapid defibrillation without endangering hospital staff.

Answers: a. Turn the defibrillator on. c. Select the appropriate energy level. d. Place the hands-free, multifunction defibrillator pads on the patient's chest. e. Check the location of other staff and call out "all clear." b. Deliver the electrical charge Rationale: This order will result in rapid defibrillation without endangering hospital staff.

The nurse observes scleral jaundice in a patient being admitted with hemolytic anemia. Which laboratory result the nurse should check? a. Schilling test b. Bilirubin level c. Stool occult blood d. Gastric acid analysis

B. Bilirubin level Rationale: Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. Other tests would not be helpful in monitoring hemolytic anemia.