Test 2

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?

1. Bleeding from the gums

2. Decreased level of consciousness

3. A nonsustained episode of ventricular tachycardia

4. An increase in blood pressure
   

2. Decreased level of consciousness

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.

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP?

1. Teaching a patient about exercise electrocardiography

2. Monitoring a patient after a transesophageal echocardiogram

3. Attaching ECG monitoring electrodes after a patient bathes

4. Checking the patient’s catheter site after a coronary angiogram
   

3. Attaching ECG monitoring electrodes after a patient bathes

UAP can be educated in standardized lead placement for ECG monitoring. Assessment of patients who have had procedures where airway maintenance (transesophageal echocardiography) or bleeding (coronary angiogram) is a concern must be done by the registered nurse (RN). Patient teaching requires RN level education and scope of practice.

The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss?

1. "Edema will be present in the legs."

2. "Crackles in the lungs will be present."

3. "Blood pressure will decrease."

4. "Pulse rate will increase."
   

4."Pulse rate will increase."

The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Although the blood pressure will decrease, it is not the earliest indicator. Edema and crackles in the lungs indicate an increase in fluid volume.

Which patient statement to the nurse is most consistent with the diagnosis of venous insufficiency?

1. “I can’t get my shoes on at the end of the day.”

2. “I have burning leg pain after I walk two blocks.”

3. “I can’t ever seem to get my feet warm enough.”

4. “I wake up during the night because my legs hurt.”

1. “I can’t get my shoes on at the end of the day.”

Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease.

Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective?

1. Hemoglobin is within normal limits.

2. Urine output 65 mL over the past hour.

3. There are no signs of hemorrhage.

4. Mean arterial pressure (MAP) is 72 mm Hg.

2. Urine output 65 mL over the past hour.

Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. Urine output should be equal to or more than 0.5 mL/kg/hr. The hemoglobin level and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. The absence of hemorrhage helps to prevent further fluid loss but does not reflect fluid balance.

A patient has HF and has been taking digoxin for 9 years. The patient is admitted with signs and symptoms of digoxin toxicity. Which signs and symptoms are associated with digoxin toxicity? (Select all that apply.)

1. Diarrhea

2. Insomnia

3. Tachycardia

4. Vomiting

5. Yellow haloes in the visual field

6. Dysuria

1)Diarrhea

4)Vomiting

5) Yellow haloes in the visual field

Vomiting, yellow haloes in the visual field, and diarrhea are classic signs of digoxin toxicity. Bradycardia, not tachycardia, will likely be noted.

Which therapy would the nurse anticipate administering for emergency care of a patient with suspected myocardial infarction (MI)?

1. Nitroglycerine, lorazepam, oxygen and warfarin

2. Oxygen, nitroglycerine, morphine and aspirin

3. Aspirin, dopamine, nitroprusside and oxygen

4. Oxygen, furosomide, nitroglycerine, meperidine
   

2. Oxygen, nitroglycerine, morphine and aspirin

AHA guidelines call for MONA to treat MI--Morphine, oxygen, nitroglycerine and aspirin. The other drugs might be used in the future treatment, but are not appropriate for initial care.

Several hours after a patient had an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 45 mL. What should the nurse anticipate will be prescribed?

1. Increased IV fluids

2. Serum creatinine level

3. Hemoglobin count

4. Additional antibiotics

1. Increased IV fluids

The decreased urine output suggests decreased renal perfusion and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient’s decreased urinary output.

After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first?

1. Patient who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache.

2. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L.

3. Patient who is taking captopril and has a frequent nonproductive cough.

4. Patient who is taking carvedilol (Coreg) and has a heart rate of 58.

2. Patient who is taking digoxin and has a potassium level of 3.1 mEq/L.

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.

 To evaluate the effectiveness of the pantoprazole (Protonix) given to a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?

1. Palpate for abdominal tenderness.

2. Auscultate bowel sounds.

3. Ask the patient about nausea.

4. Check stools for occult blood.

4. Check stools for occult blood.

Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration.

 A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate?

1. “Enoxaparin will work right away, but warfarin takes several days to begin preventing clots.”

2. “Taking both blood thinners greatly reduces the risk for another clot to form.”

3. “Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming.”

4. “Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner.”

1. “Enoxaparin will work right away, but warfarin takes several days to begin preventing clots.”

Low-molecular-weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE. Anticoagulants do not thin the blood.

The nursing assistant reports to the nurse that a client is “feeling short of breath”. The client’s blood pressure was 124/78 2 hours ago with a heart rate of 82. The nursing assistant reports that the blood pressure is now 84/44 with a heart rate of 54 BPM. The client has stated “I just don’t feel good”. Which of the following interventions should the nurse initiate? Select all that apply.

1. Inform the charge nurse of the change in condition and initiate the hospital’s rapid/emergency response team.

2. Call the physician and report the situation using SBAR format.

3. Stay with the client and reassure the client

4. Make a quick check on other assigned clients before spending the amount of time required to care for this client. Position the client in semi-Fowler’s position

5. Confirm the client’s vital signs and complete a quick assessment

1. Inform the charge nurse of the change in condition and initiate the hospital’s rapid/emergency response team.

2. Call the physician and report the situation using SBAR format.

3. Stay with the client and reassure the client

5. Confirm the client’s vital signs and complete a quick assessment

The nurse must have assessment data and verify vital signs if necessary in order to determine the action that is required. If there is a significant change in the client’s condition, the charge nurse should be notified in order to help the nurse with both this client and the nurse’s other clients. Most acute care facilities have a rapid response team that can help with emergent situations. It is important to stay with the patient and keep them calm. The PCP must be made aware of the change in the client’s condition.

A patient with acute pericarditis has markedly distended jugular veins, decreased BP, tachycardia, tachypnea and muffled heart sounds. The nurse recognizes that these symptoms occur when what happens?

1. The parietal and visceral pericardial membranes adhere to each other, preventing normal myocardial contraction

2. Excess pericardial fluid compresses the heart and prevents adequate diastolic filling.

3. Fibrin accumulation on the visceral pericardium infiltrates into the myocardium, creating generalized myocardial dysfunction.

4. The pericardial space is obliterated with scar tissue and thickened pericardium

2. Excess pericardial fluid compresses the heart and prevents adequate diastolic filling.

The patient is experiencing cardiac tamponade that consists of excess fluid in the pericardial sac, which compresses the heart and the adjoining structures, preventing normal filling and cardiac output. A scarred and thickened pericardium, adherent pericardial membranes and fibrin accumulation occur in chronic constrictive pericardidits.

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?

1. Acute pain

2. Anxiety

3. Decreased cardiac output

4. Stress management

3. Decreased cardiac output

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.

When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is important for the nurse to communicate to the health care provider before the test?

1. The patient has not eaten anything today.

2. The patient had a heart attack 1 year ago.

3. The patient is allergic to shellfish.

4. The patient’s pedal pulses are +1.

3. The patient is allergic to shellfish.

The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications, such as corticosteroids and antihistamines before the angiogram. The other information may be communicated to the health care provider but will not require a change in the usual precardiac catheterization orders or medications.

 Which information from a patient helps the nurse confirm the previous diagnosis of chronic stable angina?

1. “The pain wakes me up at night.”

2. “The pain is level 3 to 5 (0 to 10 scale).”

3. “The pain goes away after a nitroglycerin tablet.”

4. “The pain has gotten worse over the last week.”

3. “The pain goes away after a nitroglycerin tablet.”

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.

A client with symptomatic mitral valve prolapse has atrial and ventricular dysrhythmias. In addition to monitoring for decreased cardiac output related to the dysrhythmias, what is an important nursing intervention related to the dysrhythmias identified by the nurse?

1. Teach the client exercises to prevent recurrence of the dysrhythmias

2. Give sleeping pills to decrease paroxysmal nocturnal dyspnea

3. Monitor breathing pattern related to hypervolemia

4. Encourage calling for assistance when getting out of bed

4. Encourage calling for assistance when getting out of bed

Dysrhythmias frequently cause palpitations, light headedness and dizziness. The client should have assistance when changing position to avoid falls. Hypervolemia and paroxysmal nocturnal dyspnea would be apparent in the client with heart failure. Exercise will not prevent dysrhythmias

 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?

1. Check the capillary refill.
   

2. Ask about the patient’s allergies.
   

3. Auscultate the abdomen.
   

4. Auscultate the breath sounds.

4. Auscultate the breath sounds.

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.

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?

1. “Do you take aspirin daily?”
   

2. “What time did your pain begin?”
   

3. “Do you have any allergies?”
   

4. “Can you rate the pain on a 0 to 10 scale?”

2. “What time did your pain begin?”
   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.

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?

1. Increase the rate for the dopamine infusion.
   

2. Increase the rate for the sodium nitroprusside infusion.
   

3. Decrease the rate for the nitroglycerin infusion.
   

4. Decrease the rate for the 5% dextrose in normal saline infusion.

2. Increase the rate for the sodium nitroprusside infusion.
   Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.

Myocardial ischemia occurs as a result of increased oxygen demand and decreased oxygen supply. Which factors and disorders result in increased oxygen demand (Select all that apply)?

1. Sympathetic nervous system stimulation by drugs, emotions or exertion
   

2. Left ventricular hypertrophy caused by chronic hypertension
   

3. Angina in the patient with atherosclerotic coronary arteries
   

4. Hypovolemia or anemia
   

5. Narrowed coronary arteries from atherosclerosis
   

6. Increased cardiac workload with aortic stenosis

1. Sympathetic nervous system stimulation by drugs, emotions or exertion
   

2. Left ventricular hypertrophy caused by chronic hypertension
   

3. Angina in the patient with atherosclerotic coronary arteries

6. Increased cardiac workload with aortic stenosis

Increased oxygen demand is caused by increasing workload of the heart, including left ventricular hypertrophy with hypertension, SNS stimulation and anything precipitating angina. Hypovolemia, anemia and narrowed coronary arteries contribute to decreased oxygen supply

 After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first?

1. A patient who is receiving oxygen and has crackles bilaterally in the lung bases.

2. A patient who has new-onset confusion and restlessness and cool, clammy skin.

3. A patient who reported dizziness after receiving the first dose of captopril.

4. A patient who is receiving IV nesiritide (Natrecor), with a blood pressure of 100/62.

2. A patient who has new-onset confusion and restlessness and cool, clammy skin.
   
   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.

Which finding for a patient with mitral valve stenosis would be of most concern to the nurse?

1. Shortness of breath on exertion
   

2. Diastolic murmur
   

3. Right upper quadrant tenderness
   

4. Peripheral edema

1. Shortness of breath on exertion
   

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

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?

1. Participation in daily activities without chest pain
   

2. Improvement in the strength of the distal pulses
   

3. Fewer complaints of having cold hands and feet
   

4. Decreased blood pressure and heart rate

1. Participation in daily activities without chest pain
   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 b-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature.