Quiz 2

The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately? a. The patient has bilateral crackles. b. The patient has bilateral, 4+ peripheral edema. c. The patient has a loud systolic murmur across the precordium. d. The patient has a palpable thrill felt over the left anterior chest.

A Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.

While caring for a patient with aortic stenosis, the nurse establishes a nursing diagnosis of pain related to decreased coronary blood flow. An appropriate intervention by the nurse is to a. promote rest to decrease myocardial oxygen demand. b. teach the patient to use sublingual nitroglycerin for chest pain. c. educate the patient about the need for anticoagulant therapy. d. elevate the head of the bed 40 degrees to decrease venous return.

A Rationale: Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation.

A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next? a. Listen to the patient's lungs. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

A The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)? a. Fever, chills, and diaphoresis b. Urine output less than 30 mL/hr c. Petechiae on the inside of the mouth and conjunctiva d. Increase in heart rate of 15 beats/minute with walking

B Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE, but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise.

Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? a. BP is 150/90 mm Hg. b. Oxygen saturation is 89%. c. Pain level is 5/10 with a deep breath. d. Respiratory rate is 24 when lying flat.

B Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.

Which assessment information obtained by the nurse for a patient with aortic stenosis would be most important to report to the health care provider? a. A loud systolic murmur is audible along the right sternal border. b. The patient complains of chest pain associated with ambulation. c. The point of maximum impulse (PMI) is at the left midclavicular line. d. A thrill is palpable at the 2nd intercostal space, right sternal border.

B Rationale: Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill would not be unusual for a patient with aortic stenosis. A PMI at the left midclavicular line is normal.

Which information obtained by the nurse when assessing a patient admitted with mitral valve stenosis should be communicated to the health care provider immediately? a. The patient has a loud diastolic murmur all across the precordium. b. The patient has crackles audible to the lung apices. c. The patient has a palpable thrill felt over the left anterior chest. d. The patient has 4+ peripheral edema in both legs.

B Rationale: Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure and needs immediate interventions such as diuretics. A diastolic murmur and palpable thrill would be expected in a patient with mitral stenosis. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.

When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for a. angina and syncope. b. dyspnea and hemoptysis. c. JVD and peripheral edema. d. hypotension and paroxysmal nocturnal dyspnea (PND).

B Rationale: The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in dyspnea and hemoptysis. Angina and syncope are associated with aortic stenosis. JVD and peripheral edema are more common in right-sided valvular disorders. Hypotension and PND suggest aortic regurgitation.

The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history will be most pertinent to ask? a. "Do you use any illegal IV drugs?" b. "Have you had a recent sore throat?" c. "Have you injured your chest in the last few weeks?" d. "Do you have a family history of congenital heart disease?"

B Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.

The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about a. a large air leak in the water-seal chamber. b. 400 mL of blood in the collection chamber. c. complaint of pain with each deep inspiration. d. subcutaneous emphysema at the insertion site.

B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax.

A patient with a pleural effusion is scheduled for a thoracentesis. Before the procedure, the nurse will plan to a. start a peripheral intravenous line to administer the necessary sedative drugs. b. position the patient sitting upright on the edge of the bed and leaning forward. c. remove the water pitcher and remind the patient not to eat or drink anything for 6 hours. d. instruct the patient about the importance of incentive spirometer use after the procedure.

B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The lung will expand after the effusion is removed; incentive spirometry is not needed to assure alveolar expansion. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious.

When caring for the patient with infective endocarditis of the tricuspid valve, the nurse will plan to monitor the patient for a. flank pain. b. hemiparesis. c. dyspnea. d. splenomegaly.

C Rationale: Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, hemiparesis, and splenomegaly would be associated with embolization from the left-sided valves.

A patient is admitted to the emergency department with an open stab wound to the right chest. What is the first action that the nurse should take? a. Position the patient so that the right chest is dependent. b. Keep the head of the patient's bed at no more than 30 degrees elevation. c. Tape a nonporous dressing on three sides over the chest wound. d. Cover the sucking chest wound firmly with an occlusive dressing.

C The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for a. diastolic murmur. b. peripheral edema. c. shortness of breath on exertion. d. right upper quadrant tenderness.

C The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease but are not indicators of possible hypoxemia.

The nurse is caring for a patient with mitral regurgitation. Referring to the figure below, where should the nurse listen to best hear any murmur that the patient has?

D Sounds from the mitral valve are best heard at the apex of the heart, fifth intercostal space, midclavicular line.

The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Notify the surgeon and anesthesiologist. b. Wrap both the legs in a warming blanket. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.

a. Notify the surgeon and anesthesiologist.

An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first? a. Obtain the blood pressure. b. Obtain blood for laboratory testing. c. Assess for the presence of an abdominal bruit. d. Determine any family history of kidney disease.

a. Obtain the blood pressure.

A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about a. low back pain. b. trouble swallowing. c. abdominal tenderness. d. changes in bowel habits.

b. trouble swallowing.

When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Loose, bloody stools c. Hypoactive bowel sounds d. Abdominal pain with palpation

b. Loose, bloody stools

Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Check the abdominal incision for any redness. d. Teach the reason for a prolonged recovery period.

b. Monitor fluid intake and urine output.

After receiving report, which patient admitted to the emergency department should the nurse assess first? a. 67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse b. 58-year-old who is taking anticoagulants for atrial fibrillation and has black stools c. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain d. 39-year-old who has right calf tenderness, redness, and swelling after a long plane ride

c. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain

Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.

d. Help the patient to use a pillow to splint while coughing.

When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension

d. Uncontrolled hypertension

Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n) a. hemoglobin count. b. additional antibiotic. c. decrease in IV infusion rate. d. blood urea nitrogen (BUN) level.

d. blood urea nitrogen (BUN) level.