[CARDIO] POST TEST

B. Steak sauce

Steak sauce is high in sodium. A tablespoon of steak sauce can contain up to 300 milligrams of sodium. This is more than 10% of the daily recommended intake of sodium for adults.

Green leafy vegetables are a good source of nutrients, including vitamins, minerals, and fiber. They are also low in calories and sodium. Eating green leafy vegetables can help to lower blood pressure and cholesterol levels.

Apple juice is a good source of vitamins and minerals, including vitamin C and potassium. It is also low in sodium. Drinking apple juice can help to boost the immune system and improve hydration.

Ice cream is high in sugar and fat. Eating too much ice cream can lead to weight gain and other health problems, such as heart disease and diabetes. However, a small serving of ice cream may be okay for people with congestive heart failure as long as it is part of a healthy overall diet.

Nurse Nica is providing diet teaching to a patient with congestive heart failure. The nurse tells the patient to avoid it.

A. Green leafy vegetables

B. Steak sauce

C. Apple juice

D. Ice cream

A. Salt packets

Patients with heart failure need to limit their sodium intake to reduce fluid retention and improve overall heart function. Salt packets are a concentrated source of sodium and should be avoided.

B. Milk is a good source of calcium, which is important for bone health. It is also a low-sodium option.

C. Margarine is a healthier alternative to butter, as it is lower in saturated fat. It is also low in sodium.

D. Decaffeinated tea is a healthy beverage choice for patients with heart failure. It is low in sodium and caffeine, which can cause heart palpitations.

Nurse Tiffany is planning the care for a patient with heart failure. The nurse should ask the dietary department to remove which item from the meal tray before delivering to the patient. The nurse should ask the dietary department to remove which item from the meal tray before delivering it to the patient?

A. Salt packets

B. Milk

C. Margarine

D. Decaffeinated tea

A. Continue to monitor the rhythm

Isolated premature ventricular contractions (PVCs) are generally benign (not life threatening) and do not require any treatment. However, it is important to continue to monitor the rhythm to ensure that the PVCs do not become more frequent or develop into a more serious arrhythmia.

Notify if:

- More than 6 occur in 1 minute

- Occur in pairs or triplets

- Multifocal

- Occur on or near a T wave.

B. While it is important to keep the MD informed of any changes in the patient's condition, notifying the MD for isolated PVCs is not necessary.

C. Defibrillation is only necessary for life-threatening arrhythmias, such as ventricular fibrillation or ventricular tachycardia. Isolated PVCs are not life-threatening.

D. Lidocaine is a medication that is used to treat ventricular arrhythmias. However, it is not typically used for isolated PVCs.

Nurse Neneth notes isolated premature ventricular contraction on the cardiac monitor. The appropriate nursing action is to

A. Continue to monitor the rhythm

B. Notify the MD

C. Prepare for defibrillation

D. Prepare lidocaine

A. Asking the patient to take the pulse in the wrist or neck and checks accuracy of the patient's reading

B. Determining if the patient knows not to operate a microwave oven

This can be done but with precaution (avoid using microwaves or to keep at least 12 inches away from the appliance). Microwaves emit electromagnetic fields that can interfere with the pacemaker's functioning.

C. Dizziness can be a symptom of pacemaker malfunction, but it is also a common symptom of other conditions.

D. Asking the patient to move arms and shoulders vigorously to check pacemaker functioning is not a recommended way to assess pacemaker function, as it could damage the pacemaker leads.

Mrs. Daniela comes to the clinic for follow-up after her permanent pacemaker insertion. The nurse determines the patient's ability for self- care of the pacemaker by:

A. Asking the patient to take the pulse in the wrist or neck and checks accuracy of the patient's reading

B. Determining if the patient knows not to operate a microwave oven

C. Determining if the patient is able to expect feelings of dizziness

D. Asking the patient to move arms and shoulders vigorously to check pacemaker functioning

D. Apply a gauze roll and tape the edge of the roll onto the bandage

Rationale:

Arterial ulcers or ischemic ulcers, are caused by poor perfusion to the lower extremities. The overlying skin and tissues are then deprived of oxygen, killing these tissues and causing the area to form an open wound. Avoid pressure and damage in skin integrity.

Cancel A and B due to added pressure due to skin which should be avoided.

Montgometry straps are a type of non-adherent dressing that are commonly used to secure dressings on ischemic arterial leg ulcers (also with abdominal binders). They are soft, flexible, and easy to apply, and they do not stick to the skin. However, tying the edges together adds more pressure.

A nurse has applied the prescribed dressing to the leg of Mr. Pompey, a patient with an ischemic arterial leg ulcer. The nurse would use which of the following methods to cover the dressing?

A. Apply a large, soft pad, and tape it to the skin

B. Apply a gauze roll and tape it to the skin

C. Apply small Montgometry straps and tie the edges together

D. Apply a gauze roll and tape the edge of the roll onto the bandage

D. Place the patient on continuous cardiac monitoring

MI is a serious medical condition that occurs when blood flow to a portion of the heart is blocked, depriving the heart muscle of oxygen. Continuous cardiac monitoring is essential to assess their heart rhythm, HR, and BP.

A. O2 therapy should be around 1-3 LPM only. O2 therapy is not routinely indicated for patients with MI unless they have hypoxemia. Too much oxygen can lower CO2.

B. Should be in KVO rate = 20-30 or 10-50 drops/min to establish line only. 150 ml/hour is too fast. IV fluid therapy is often initiated in patients with MI to maintain BP and organ perfusion.

C. Thrombolytic therapy is used to dissolve blood clots that are blocking blood flow to the heart & most effective if administered within the first few hours of an MI. However, not all patients with MI are candidates for it. Wait for doctor's order.

Nurse Marie admits a patient with myocardial infarction to the coronary care unit. The nurse plans to do which of the following in delivering care to this patient?

A.Administer 02 at 6 lpm via nasal cannula

B. Infuse IV at a rate of 150 ml/hour

C. Begin thrombolytic therapy

D. Place the patient on continuous cardiac monitoring

D. Placing the patient on NPO after midnight on the night before the test

Venography is a diagnostic imaging procedure that uses contrast dye to visualize veins. It is typically performed on an outpatient basis and does not require the patient to fast. In fact, it is usually recommended that patients eat and drink normally before the procedure to avoid dehydration and potential complications.

A. Asking the patient about allergies to iodine or shellfish is important as iodine-based contrast dye is used in venography.

B. Obtaining informed consent is a standard procedure for any medical or surgical intervention.

C. Determining the location and strength of the peripheral pulses is an important step in the pre-procedure assessment, as it helps to identify potential sites for injection of the contrast dye. It also helps to assess the patient's overall circulatory status.

A nurse is preparing a patient for venography. The nurse understands that which of the following is unnecessary before this procedure?

A. Asking the patient about allergies to iodine or shellfish

B. Obtaining a signed consent form

C. Determining the location and strength of the peripheral pulses

D. Placing the patient on NPO after midnight on the night before the test

C. Patient may feel certain sensations at various points during the procedure

These sensations are typically harmless and subside shortly after the procedure.

Fluttery feeling: passage of catheters through the heart valves.

Flushed warm feeling: contrast dye.

Desire to cough: catheter passing through the trachea.

Palpitations: stimulation of the heart by the catheter/contrast dye.

A. CC is typically performed in a specialized procedure room called a cardiac catheterization laboratory (cath lab), not in an OR.

B. CC typically takes 1-2 hours, not 8 hours. The patient may experience some discomfort from lying still for an extended period, but fatigue and aches are not common side effects.

D. The initial catheter insertion may cause a brief stinging sensation, but it is generally not painful due to local anesthesia. The patient may experience some discomfort during the procedure, but it is usually well-tolerated.

A nurse is caring for a patient scheduled to undergo a cardiac catheterization for the first time. The nurse tells Mrs. Sonia that the:

A. Procedure is performed in the operating room

B. Patient may feel fatigue and have various aches, because it is necessary to lie quietly on hard X-ray table for 8 hours

C. Patient may feel certain sensations at various points during the procedure, such as fluttery feeling, flushed warm feeling, desire to cough or palpitations

D. Initial catheter insertion is quite painful, after that, there will be no pain

A. Long, firm strokes from distal to proximal areas

B. Firm circular strokes from proximal to distal areas

promote venous flow by squeezing the veins and pushing the blood towards the heart

Venous return is the flow of blood back to the heart from the veins. Smooth, light strokes back and forth from proximal to distal areas can help to promote venous return by massaging the muscles and pushing the blood towards the heart.

B. Circular strokes can be too constricting and may impede venous return

C. Short, patting strokes are not effective.

D. Smooth, light strokes may not be enough to stimulate venous flow.

Nurse Lisa is giving a bed bath to a patient who is on strict bed rest. In order to increase venous return from the extremities, the nurse bathes the patient's extremities by using:

A. Long, firm strokes from distal to proximal areas

B. Firm circular strokes from proximal to distal areas

C. Short, patting strokes from distal to proximal areas

D. Smooth, light strokes back and forth from proximal to distal areas

D. Document the finding and continue to assess the bowel sounds

The absence of bowel sounds after abdominal aortic aneurysm repair is a common occurrence and is not necessarily indicative of a serious problem. However, it is important to continue to assess the bowel sounds to rule out any potential complications, such as paralytic ileus. Bowel sounds return in 3-4 days usually.

A. Calling the MD is not necessary at this time, as the absence of bowel sounds is a common finding after abdominal aortic aneurysm repair. However, if the patient develops other symptoms, such as abdominal pain, distention, or nausea, the MD should be notified.

B. There is no need to remove the NGT simply because the patient has absent bowel sounds.

C. Feeding the patient prematurely can worsen paralytic ileus if it is present. It is important to wait for the bowel sounds to return before feeding the patient.

Mr. Ally had an abdominal aortic aneurysm repair 2 days ago. The nurse performs an abdominal assessment and notes the absence of bowel sounds. The nurse should:

A. Call the MD

B. Remove the NGT

C. Feed the patient

D. Document the finding and continue to assess the bowel sounds

D. The patient reports absence of dyspnea and anginal pain on activity

This finding indicates that the patient's cardiac output is adequate to meet their metabolic demands and that they are tolerating activity well. This is the most direct and reliable indicator that an expected outcome for decreased cardiac output has been met.

A. While a CO of 3 LPM is within the normal range, it is not a direct measure of the patient's tolerance for activity.

B. A heart rate of 50 beats per minute is on the low end of the normal range and may be a sign of bradycardia, which can be a complication of myocardial infarction

C. This finding suggests that the patient's condition is not stable and that they are not tolerating activity well.

A nurse is evaluating the outcomes of care for a client who experienced an acute myocardial infarction. Which of the following findings indicate that an expected outcome for the nursing diagnosis of decreased cardiac output has been met?

A. CO of 3 LPM when measured with a pulmonary artery catheter

B. Cardiac monitor shows a heart rate of 50 beats per minute after the patient has eaten dinner

C. The patient complains of symptoms that require immediate action

D. The patient reports absence of dyspnea and anginal pain on activity

B. Marks the location of pedal pulses on the right leg

Assessing pedal pulses on the right leg is crucial for evaluating the patient's circulation and identifying any potential pre-existing impairment in blood flow to the lower extremity. This assessment provides baseline information about the patient's perfusion status and allows the nurse to monitor for any changes postoperatively.

A. Completing a preoperative checklist is essential doesn't directly address the nursing diagnosis of Ineffective Tissue Perfusion in the right leg.

C. Bladder fullness can cause discomfort and interfere with perioperative care, but it's not directly related to the patient's circulation or perfusion status.

D. Coagulation studies are important for assessing bleeding risk, but they don't directly reflect the patient's tissue perfusion status in the right leg.

A patient is scheduled for a right femoral-popliteal bypass graft. The patient has a nursing diagnosis of Ineffective Tissue Perfusion. The nurse takes which of the following actions before surgery to address this nursing diagnosis?

A. Completes a preoperative checklist

B. Marks the location of pedal pulses on the right leg

C. Checks the client has voided before surgery

D. Checks the results of any baseline coagulation studies

D. Call MD

Mr. Titio's symptoms are concerning for compartment syndrome, a serious complication that can occur after peripheral bypass surgery. Compartment syndrome is caused by excessive pressure within a muscle compartment, which can damage nerves and blood vessels. Symptoms of compartment syndrome include pain that is worse with movement, paresthesia, and weakness.

The MD will need to assess the patient and determine if they need surgery to relieve the pressure in the muscle compartment.

A. Narcotics may help to relieve Mr. Titio's pain, but they will not address the underlying cause of compartment syndrome.

B. Applying warm moist heat may help to reduce inflammation, but it will not address the compartment syndrome.

C. Applying ice may help to reduce inflammation, but it may also worsen Mr. Titio's pain.

Mr. Titio, who underwent peripheral bypass surgery 16 hours ago, complains of increasing pain in the leg at rest which worsens with movement and is accompanied by paresthesia. The nurse should take which of the following actions?

A. Administer narcotics

B. Apply warm moist heat

C. Apply ice

D. Call MD

C. Checks the BP in the right arm

Before 15-30 minutes, if the patient has consumed any caffeine or nicotine product, postpone blood pressure taking to prevent inaccurate results.

It is important to confirm the blood pressure reading before taking any further action. This is because a single high blood pressure reading may not be accurate, and it could be caused by factors such as anxiety, exercise, or caffeine.

A. Notifying the MD is not necessary at this time, as the nurse needs to confirm the blood pressure reading before taking any further action.

B. Kidney disorders can be a cause of high blood pressure, but it is not necessary to inquire about this at this time.

D. If not possible on the other arm, wait for at least 2 minutes in taking BP on the same arm.

The nurse in the OPD takes a patient's BP in the left arm and notes that it is 200/118 mmHg. The nurse would:

A. Notify MD

B. Inquire about the presence of kidney disorders

C. Checks the BP in the right arm

D. Recheck the pressure in the same arm within 30 seconds

D. Adjusting the bed to provide a comfortable knee bend

Patient should not be allowed to do knee bending due to impede circulation in the popliteal area and obstruction of venous flow.

Rationale:

Moist heat can increase inflammation and worsen the symptoms of thrombophlebitis. The other options, compression stockings, elevating the feet, and adjusting the bed, are all appropriate measures to reduce swelling and promote venous return, which can help to prevent blood clots from forming.

A. Compression stockings help to compress the veins and reduce swelling, which can help to prevent blood clots from forming.

B. Moist heat can help to reduce pain and inflammation in the affected area.

C. Elevating the feet helps to reduce swelling by promoting venous return.

A hospitalized patient has been diagnosed with thrombophlebitis. Nurse Alfred would avoid doing which of the following during the care of this patient?

A. Applying compression stockings

B. Applying moist heat to the leg

C. Elevating the feet above heart level

D. Adjusting the bed to provide a comfortable knee bend

C. Impaired comfort

Acute myocardial infarction (AMI), commonly known as a heart attack, is a serious medical condition that occurs when blood flow to a portion of the heart is blocked, depriving the heart muscle of oxygen. Patients with AMI often experience severe chest pain, shortness of breath, and anxiety. These symptoms can significantly impair comfort and quality of life.

A. While anxiety is a common symptom of AMI, it is not the primary nursing concern in the acute phase.

B. Interrupted family processes may become a concern later in the patient's recovery, but it is not a primary nursing diagnosis in the acute phase.

D. Powerlessness may also be a concern for patients with AMI, but it is not the primary nursing diagnosis in the acute phase.

Nurse Theresa develops a plan of care for a patient admitted to the hospital with a diagnosis of acute MI. The priority nursing diagnosis in the acute phase would be.

A. Anxiety

B. Interrupted family processes

C. Impaired comfort

D. Powerlessness

A. Bibasilar crackles

Bibasilar crackles are a type of adventitious breath sound that can be heard over the bases of the lungs. They are caused by fluid in the alveoli, which are the small air sacs in the lungs. The presence of bibasilar crackles is a sign of pulmonary edema, which is a condition in which fluid accumulates in the lungs and a common complication of Excess Fluid Volume.

The rest of the choices are signs of hypovolemia.

In FVE:

Pulse must be bounding.

BP must be elevated.

Neck veins must be distended

A patient has a nursing diagnosis of Excess Fluid Volume. After assessing the patient, the nurse records which assessment data in the medical record that supports continued use of this nursing diagnosis?

A. Bibasilar crackles

B. Weak pulse

C. Decreased BP

D. Flat neck veins with the head of the bed at 45 degrees

D. The tube may be occluded

A sudden decrease in chest tube drainage from 75 mL to 5 mL in the second hour after cardiac surgery is a concerning finding that could indicate an occlusion of the chest tube. A chest tube is a drainage tube that is inserted into the chest cavity to remove air, blood, or fluid. If the chest tube is occluded, it will not be able to drain properly, and this could lead to complications such as pneumothorax (air in the chest cavity) or hemothorax (blood in the chest cavity).

A. It is unlikely that the lung has fully re-expanded in just two hours after cardiac surgery.

B. A sudden decrease in chest tube drainage is not normal and should be investigated if there is a decrease in mL.

C. Coughing and deep breathing can help to promote lung expansion and drainage, but they are not a substitute for investigating a sudden decrease in chest tube drainage.

Ms. Juliet is admitted to the cardiac intensive care unit following cardiac surgery. The nurse notes that in the first hour after admission, the chest tube drainage was 75 mL. During the second hour, the drainage dropped to 5 mL. The nurse interprets that.

A. The lung has fully re-expanded

B. This is normal

C. The patient needs to cough and deep breathe

D. The tube may be occluded

C. I need to keep my legs and arms cool

Thromboangitis obliterans (Buerger's) is an inflammatory disease that causes the formation of blood clots in the small and medium-sized arteries of the hands and feet. This can lead to pain, numbness, and tissue damage. Warmth can help to improve circulation in the affected areas, so it is important for patients with thromboangitis obliterans to keep their legs and arms warm. Cold impedes blood circulation through vasoconstriction.

A. Smoking is a major risk factor for thromboangitis obliterans, so quitting smoking is essential for controlling the disease.

B. I will need to take nifedipine as directed: Nifedipine is a calcium channel blocker that can help to improve blood flow to the affected areas.

D. Skin breakdown is a common complication of thromboangitis obliterans, so it is important for patients to watch for signs and symptoms such as redness, swelling, and drainage.

A nurse teaches Mr. Carlo, a patient with thromboangitis obliterans about measures on how to control the disease process. The nurse determines that the patient needs further instructions about these measures if the patient states which of the following?

A. I need to stop smoking immediately

B. I will need to take nifedipine as directed

C. I need to keep my legs and arms cool

D. I need to watch for signs and symptoms of skin breakdown

C. Supine with the head of bed elevated at 30 to 60 degrees angle

Pericardiocentesis is a procedure that involves inserting a needle into the pericardial sac, the sac that surrounds the heart, to remove excess fluid. The fluid buildup, known as pericardial effusion, can put pressure on the heart and prevent it from filling properly. Positioning the patient supine with the HOB elevated at 30 to 60 degrees helps to displace the fluid away from the heart and make it easier to remove during the procedure.

A. Lying on the left side with a pillow under the chest wall is not ideal as it can make it difficult to access the pericardial sac.

B. Lying on the right side with a pillow under the head is also not ideal as it can put pressure on the heart and make it more difficult to remove fluid.

D. The Trendelenburg position cause blood to pool in the legs and make it more difficult to remove fluid from the pericardial sac.

A nurse is assisting to position Mr. Arnel, a patient for pericardiocentesis to treat cardiac tamponade. The nurse positions the patient:

A. Lying on the left side with a pillow under the chest wall

B. Lying on the right side with a pillow under the head

C. Supine with the head of bed elevated at 30 to 60 degrees angle

D. Supine with slight Trendelenburg position

D. Moving slowly from a sitting to a standing position.

Patients with cardiomyopathy have a weakened heart muscle, which can make them more susceptible to dizziness and lightheadedness, especially when changing positions quickly. Moving slowly from a sitting to a standing position helps to prevent orthostatic hypotension, which is a drop in blood pressure that can occur when a person stands up too quickly.

A. Pain is not a common symptom of cardiomyopathy, and it is not a major safety concern.

B. Patients should talk to their doctor or pharmacist about which over-the-counter drugs are safe for them to take.

C. Vasodilators are medications that help to widen blood vessels, which can improve blood flow to the heart. However, they should only be taken as prescribed by a doctor.

A nurse is teaching a patient with cardiomyopathy about home care safety measures. Nurse Isagani should emphasize the most important measure to ensure client safety, which is:

A. Assessing pain

B. Avoiding over-the-counter drugs

C. Administering vasodilators

D. Moving slowly from a sitting to a standing position

D. Cuts need to be avoided.

Patients with valvular heart disease are at an increased risk of developing infective endocarditis, a serious infection of the inner lining of the heart. Infective endocarditis can occur if bacteria enter the bloodstream and attach to damaged heart valves. Cuts from shaving can provide a pathway for bacteria to enter the bloodstream.

They are also taking anticoagulant therapy to prevent thrombus formation so cuts may induce bleeding.

A. While it is true that any cut can potentially cause infection, it does not address the need to avoid bleeding and thrombus formation.

B. While it is true that electric razors can be disinfected, this is not the primary reason why they are recommended for patients with valvular heart disease.

C. All razors should be cleaned and disinfected regularly to prevent the spread of bacteria.

A nurse instructs Mr. Marvin, a patient with a diagnosis of valvular heart disease to use an electric razor for shaving. The nurse tells the patient the importance of this, which is:

A. Any cut may cause infection

B. Electric razors can be disinfected

C. All straight razors contain bacteria

D. Cuts need to be avoided

A. Placing the patient's bed in the Fowler's position

After a femoral artery angiogram, the patient should be kept in a flat position with the puncture site immobilized for at least 4-6 hours to prevent bleeding and dislodgement of the femoral artery catheter. Placing the patient in the Fowler's position can increase blood flow to the lower extremity and put undue pressure on the puncture site, increasing the risk of bleeding.

A. Placing the patient's bed in the Fowler's position: This position helps to reduce edema and improve breathing.

B. Encouraging the patient to increase fluid intake is important to prevent dehydration and help to flush out contrast dye.

D. Resuming prescribed pre-catheterization medications is generally appropriate, but the nurse should check with the physician to ensure that there are no contraindications for resuming medications after the procedure.

A nurse caring for a patient during the recovery phase following MI. An angiogram using the femoral artery approach is performed to assess the degree of coronary artery thrombosis. Which nursing action following the procedure is unsafe for the patient?

A. Placing the patient's bed in the Fowler's position

B. Encouraging the patient to increase fluid intake

C. Instructing the patient to move the toe when checking circulation, motion and sensation

D. Resuming prescribed pre-catheterization medications

D. O2 by nasal cannula

ABCDE = breathing first

A. ECG can effectively identify the type of ACS and guide the patient's treatment plan promptly.

B. A chest X-ray can help to rule out other causes of chest pain, such as pneumonia or pneumothorax.

C. Blood tests can be used to measure troponin and CPK, which are enzymes that are released into the bloodstream when heart muscle is damaged.

A patient is admitted to the emergency department with complaints of severe, radiating chest pain. The patient is extremely restless, frightened and dyspneic. Immediate admission orders include O2 by nasal cannula at 4 lpm, troponin, CPK, chest X-ray, and 12-lead ECG. Which action would the nurse take first?

A. ECG

B. X-ray

C. Blood extractions

D. 02 by nasal cannula

B. Chronic pain, related to nonhealing arterial ulcerations

The patient's complaint of pain that has lasted for over a year and their statement of feeling discouraged and hopeless are indicative of chronic pain. The pain is likely related to the patient's nonhealing arterial ulcerations, which can be a source of ongoing discomfort and distress.

A. Acute pain is typically short-lived and is not associated with a chronic condition like chronic arterial leg ulcers.

C. While fatigue can be a symptom of chronic pain, it is not the primary nursing diagnosis in this case.

D. Ineffective coping is a nursing diagnosis that is more appropriate for patients who are having difficulty managing their emotional and psychological responses to a chronic illness. The patient's primary concern is the physical pain from their nonhealing ulcerations.

A patient with chronic arterial leg ulcers complains of pain and tells the nurse, "I'm so discouraged. I have had this pain for over a year now. The pain never seems to go away. I'll never get better." Nurse Gie formulates which nursing diagnosis for this patient?

A. Acute pain, related to the effects of leg ischemia

B. Chronic pain, related to nonhealing arterial ulcerations

C. Fatigue, related to lack of sleep and frustrations will illness D. Ineffective coping, related to chronic illness

D. The ability to comply with anticoagulant therapy for life

Patients with mechanical heart valves require lifelong anticoagulant therapy to prevent blood clots from forming on the valve. This is because mechanical valves are made of synthetic materials that do not have the same non-thrombogenic properties as natural heart valves. Failure to comply with anticoagulant therapy can lead to serious complications, such as stroke, pulmonary embolism, and valve thrombosis.

A. While body image concerns can be a concern for patients with mechanical heart valves, it is not essential to assess before the surgery is done.

B. Cardiac rehabilitation can be beneficial for patients with heart valve disease, but it is not essential to assess before the surgery is done.

C. The physical demands of the patient's lifestyle should be considered when planning for surgery but not the priority.

A patient with valvular disease is being considered for mechanical valve replacement. Which is essential to assess before the surgery is done?

A. The likelihood of the client experiencing body image problems B. The ability to participate in a cardiac rehabilitation program

C. The physical demands of the patient's lifestyle

D. The ability to comply with anticoagulant therapy for life

A. Smoking cessation program

Smoking cessation is the most important lifestyle change for patients with Buerger's disease. Smoking is the primary cause of Buerger's disease, and quitting smoking is essential for preventing the progression of the disease and improving the patient's overall health.

B. Pain is a common symptom of Buerger's disease, and pain management can help to improve the patient's quality of life.

C. A dietician can help the patient develop a healthy eating plan that supports their overall health.

D. A medical social worker can provide support and resources to the patient as they cope with the lifestyle changes needed to manage Buerger's disease.

In planning care for the patient with Buerger's Disease, Nurse Faye incorporates measures to help the patient cope with the lifestyle changes needed to control the disease process. The nurse can accomplish this by recommending a:

A. Smoking cessation program

B. Pain management

C. Consult with a dietician

D. Referral to a medical social worker

D. The ECG electrodes are painless and will record the electrical activity of the heart

This explanation is the most appropriate because it is simple, reassuring, and accurate. It provides the patient with some basic information about the test and helps to alleviate their anxiety by emphasizing that the electrodes are painless.

A. The ECG can give the doctor information about what might be wrong with your heart. This explanation is too vague and could increase the patient's anxiety.

B. It is important to lie still during the procedure. This explanation is important, but it is not the most reassuring thing to say to a patient who is anxious about the test.

C. It should only take about 20 minutes to complete the ECG tracing. This explanation is accurate, but it may not be relevant to the patient's primary concern, which is their anxiety about the test.

An older patient who has never been hospitalized before is to have a 12-lead ECG. The nurse would alleviate the patient's anxiety about the test by giving which of the following explanations?

A. The ECG can give the doctor information about what might be wrong with your heart.

B. It is important to lie still during the procedure

C. It should only take about 20 minutes to complete the ECG tracing

D. The ECG electrodes are painless and will record the electrical activity of the heart

B. Consider stress management

Raynaud's disease is a condition that causes the fingers and toes to become numb and discolored in response to cold or stress.

Stress management techniques, on the other hand, can help the patient reduce their overall stress levels and improve their Raynaud's symptoms. These techniques include relaxation exercises, mindfulness meditation, and cognitive-behavioral therapy.

A. Suggesting that the patient change jobs is not a realistic or practical solution.

C. While a psychologist can help the patient develop stress management skills, it is not the first step in addressing their concerns.

D. Earplugs may help to reduce environmental stress, but they are not a specific treatment for Raynaud's disease.

A patient with Raynaud's disease tells the nurse that he has a stressful job and does not handle stressful situations well. Nurse Morrien most appropriately guides the patient to:

A. Change jobs

B. Consider stress management

C. Seek a psychologist

D. Use earplugs to minimize environmental noise

B. Walks as tolerated, including stairs and out of doors

Following an abdominal aortic aneurysm repair, patients are typically advised to avoid strenuous activities that could put strain on the incision or the graft. This includes activities such as lifting heavy objects, mowing the lawn, and playing golf.

Walking is a safe and beneficial activity for patients recovering. It helps to promote circulation, reduce the risk of blood clots, and improve overall fitness. Patients should start slowly and gradually increase their walking distance and intensity as tolerated.

A. Lifting heavy objects can put strain on the incision and the graft, which could lead to complications.

C. Mowing the lawn requires bending, twisting, and lifting, which could put strain on the incision and the graft.

D. Golf involves activities such as swinging a club and carrying golf clubs, which could put strain on the incision and the graft.

A nurse provided instructions to a patient being discharged from the hospital to home after an abdominal aortic aneurysm repair. Nurse Jillianne determines that the patient stated that an appropriate activity would be to:

A. Lift objects up to 30 pounds

B. Walks as tolerated, including stairs and out of doors

C. Mow the lawn

D. Play golf

B. Intermittent claudication.

is a common symptom of long-standing insufficiency of arterial blood supply, also known as peripheral artery disease. It is characterized by pain, cramping, or weakness in the legs that occurs with activity and goes away with rest. This is because the narrowed arteries are not able to provide enough blood to the muscles, especially during exercise.

A. Paralysis is loss of voluntary movement, while paresthesia is a tingling or prickling sensation. Neither of these symptoms is specific to PAD.

C. Sudden onset of severe pain is more suggestive of acute arterial occlusion, such as a blood clot that blocks an artery.

D. Anesthesia is loss of sensation, while tingling is a prickling or burning sensation. Both of these symptoms can be present in PAD, but they are not as specific as intermittent claudication.

Which of the following would Nurse Harmony expect to be present in a patient with a long-standing insufficiency of arterial blood supply?

A. Paralysis of paresthesia

B. Intermittent claudication

C. Sudden onset of severe pain

D. Anesthesia or tingling sensation

A. Femoral.

When there is an occlusion of the left popliteal artery, the femoral pulse, which is located just below the inguinal ligament, will be present. This is because the femoral artery is the main artery that supplies blood to the lower leg, and it is located upstream of the occlusion.

The popliteal, dorsalis pedis, and posterior tibial pulses will be absent because they are located downstream of the occlusion and will not receive any blood flow.

When assessing the pulses of a patient with an occlusion of the left popliteal artery, Nurse Ramon may expect which of the following pulses of the left extremity to be present?

A. Femoral

B. Popliteal

C. Dorsalis pedis

D. Posterior tibial

C. Moving and exercising leg frequently.

Moving and exercising the legs frequently is one of the most important measures to prevent venous thrombosis (VT). This is because it helps to promote blood flow in the legs and reduces the risk of blood clots forming.

A. Avoiding ambulation can actually increase the risk of VT. This is because it can lead to pooling of blood in the legs, which makes it easier for clots to form.

B. Hyperflexing the knees can put pressure on the veins in the legs, which can increase the risk of VT.

D. Support stockings can help to compress the veins in the legs and prevent blood from pooling, which can reduce the risk of VT.

While caring for a patient who recently had surgery, Nurse Marie realizes that patient is at risk for venous thrombosis. Which measure would help prevent venous thrombosis?

A. Avoiding ambulation

B. Hyperflexing the knees

C. Moving and exercising leg frequently

D. Avoiding the use of support stockings

A. Applying a heating pad to the patient's feet

Patients with arterial insufficiency have decreased sensation in their extremities, making them more susceptible to burns from heat sources. Applying a heating pad to the patient's feet could cause burns due to the patient's impaired ability to feel heat.

B. Warm stockings can help to keep the patient's feet warm without the risk of burns.

C. Exercise can help to improve blood flow to the feet and reduce the risk of further complications from arterial insufficiency.

D. Increasing the room temperature slightly can help to keep the patient's feet warm and comfortable.

Mr. Romero, a 65 year old diabetic patient with arterial insufficiency in the legs, complains that his feet are cold. Which nursing measures are contraindicated?

A. Applying a heating pad to the patient's feet

B. Applying warm stockings

C. Encouraging exercise

D. Increasing the room temperature slightly

C. Taking measurements with the patient standing

Standing can cause edema to pool in the dependent extremities, leading to inaccurate measurements. Leg measurements should be taken with the patient in a lying position to ensure consistency and accuracy.

A. Taking measurements with the patient in a dorsal recumbent position is an appropriate position for taking leg measurements as it helps to eliminate the effects of gravity on fluid distribution.

B. Using a felt-tipped pen to mark the position of the measuring tape on a patient's leg is an appropriate practice as it ensures consistent placement of the measuring tape for subsequent measurements.

D. Taking bilateral measurements is an essential practice to identify any asymmetry in leg circumference, which could indicate an underlying issue.

The nurse takes leg measurements to detect swelling. All of the following actions are appropriate except:

A. Taking measurements with the patient in a dorsal recumbent position

B. Using a felt-tipped pen to mark the position of the measuring tape on a patient's legs

C. Taking measurements with the patient standing

D. Taking bilateral measurements

C. Apply them in the morning before ambulation

Mrs. Cortez to apply the support stockings in the morning before ambulation. This is because the stockings will be most effective at preventing edema (swelling) if they are applied before the legs have had a chance to swell during the day (before standing up) or before gravity pulls the circulation downwards.

A. Applying the stockings at night can actually make edema worse, as the legs will have a chance to swell while the patient is sleeping.

B. Roll down the top of the stockings to the desired length can defeat the purpose of the stockings, as it can reduce the amount of compression that is applied to the legs.

D. Remove them only once a week is not hygienic, and it can also increase the risk of edema.

When instructing Mrs. Cortez on the proper use of support stockings, the nurse should tell her to

A. Apply them in the evening before sleeping

B. Roll down the top of the stockings to the desired length

C. Apply them in the morning before ambulation

D. Remove them only once a week

B. Upright position

Patients with acute ventricular heart failure experience shortness of breath due to fluid buildup in the lungs. Placing the patient in an upright position helps to improve lung expansion and reduce shortness of breath.

A. Dorsal recumbent position with elevated feet: This position can worsen shortness of breath by increasing fluid accumulation in the lungs.

C. Low Fowler's position with elevated knees: This position can provide some relief for shortness of breath, but it is not as effective as the upright position.

D. Left lateral Sim's position: This position is not appropriate for patients with acute ventricular heart failure as it can make it difficult for them to breathe.

Mr. Origenes is in the acute phase of ventricular heart failure. To alleviate his symptoms, the nurse should place him on

A. Dorsal recumbent position with elevated feet

B. Upright position

C. Low Fowler's position with elevated knees

D. Left lateral Sim's position

C. Boiled egg sandwich on low-sodium toast; lettuce; tomato; onion salads; banana; skim milk

Moderate sodium, Moderate potassium, Suitable

A. Bologna sandwich on low-sodium bread, carrot sticks, orange, and skim milk

Processed meats like bologna are typically high in sodium.

B. Tuna fish, noodle and vegetable casserole, banana, and coffee

Like other canned foods, tuna and noodle can be high in sodium. Coffee can cause palpitations.

D. Chicken sandwich on low-sodium bread, celery sticks, apple tea with lemon

Low/High sodium, Moderate potassium

Chicken sandwich may have mayonnaise.

Mr. Ignacio is placed on a strict low-sodium, high - potassium diet. Which lunch menu is most appropriate for him?

A. Bologna sandwich on low-sodium bread, carrot sticks, orange and skim milk

B. Tuna fish, noodle and vegetable casserole, banana and coffee

C. Boiled egg sandwich on low-sodium toast; lettuce; tomato; onion salads; banana; skim milk

D. Chicken sandwich on low-sodium bread, celery sticks, apple tea with lemon

C. Supporting his decision to continue smoking if it relaxes him

All of the following measures would increase Mrs. Llanes' compliance with treatment except:

A. Helping him identify ways to incorporate treatments into his present life- cycle

B. Encouraging him to participate in a support group for hypertensive individuals

C. Supporting his decision to continue smoking if it relaxes him D. Providing written instructions

B. Bathroom privileges and self-care activities.

Patients with MI typically require a period of rest to allow the heart muscle to heal. However, they should also be encouraged to engage in light activities, such as bathroom privileges and self-care activities, to promote mobility and prevent complications.

A. Strict bed rest is no longer recommended for most patients with MI. Prolonged bed rest can increase the risk of complications, such as deep vein thrombosis (DVT) and pneumonia.

C. Unsupervised hallway ambulation may be too strenuous for some patients with MI, especially in the early stages of recovery. The nurse should closely monitor the patient's response to activity and adjust their activity level accordingly.

D. The nurse should assess the patient's individual condition and tolerance for activity before allowing them to engage in unrestricted activity.

A patient with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. Nurse Beltran plans to allow for which of the following client activities?

A. Strict bed rest for 24 hours

B. Bathroom privileges and self-care activities

C. Unsupervised hallway ambulation

D. Ad lib activities

A. Review the intake and output records for the last 2 days

Bilateral edema in the lower extremities is a common sign of fluid overload in patients with MI. Reviewing the patient's I&O records for the last 2 days can help to determine if the patient is taking in more fluids than they are excreting.

B. Change the time of diuretic administration from morning to evening may not be effective in reducing edema. The nurse should first determine the cause of the edema before the doctors makes any changes to the patient's medication regimen.

C. A sodium restriction may be helpful in reducing edema, but it is important to discuss this with the physician before making any changes to the patient's diet.

D. Daily weighing can be helpful in monitoring fluid status, but it is not the most immediate step in addressing the patient's edema.

Nurse Melanie notes bilateral edema in the lower extremities of a patient with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next?

A. Review the intake and output records for the last 2 days

B. Change the time of diuretic administration from morning to evening

C. Request a sodium restriction of 1 g/day from the physician

D. Order a daily weighs starting on the following morning

B. Premedicate the patient with an analgesic

preferably for the first 48 to 72 hours after cardiac surgery to enable the patient to best tolerate ambulation since ambulation (in cardiac rehabilitation) after cardiac surgery can be painful due to incisional pain, sternal instability, and pulmonary complications.

C. Provide the patient with a walker

They are not encouraged to move

A. Coughing and deep breathing can help to expand the lungs and improve oxygenation, but it is not the most important factor in enabling the patient to tolerate ambulation.

C. A walker can provide support and stability during ambulation, but it will not relieve pain.

D. Telemetry equipment is used to monitor the patient's heart rhythm, and it should not be removed before ambulation. The nurse should coordinate with the telemetry technician to ensure that the equipment is properly secured during ambulation.

Nurse Ignacio is preparing to ambulate a patient on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the patient to best tolerate the ambulation?

A. Encourage the patient to cough and deep breath

B. Premedicate the patient with an analgesic

C. Provide the patient with a walker

D. Remove telemetry equipment

A. Check the patient status and lead placement

When the cardiac monitor alarm sounds and there are no electrocardiogram complexes on the screen, the most likely cause is a problem with the monitor or the patient's leads. Checking the patient's status and lead placement will help to identify the cause of the alarm and determine the appropriate action.

B. Pressing the recorder button will not resolve the problem if there are no electrocardiogram complexes on the screen. This would only be appropriate if the alarm was sounding due to an abnormality in the patient's heart rhythm.

C. Calling the MD would be premature at this point. The nurse should first check the patient's status and lead placement before calling the MD to report the alarm.

D. A code blue is only called for a patient who is unresponsive or not breathing. In this case, the patient is still responsive and breathing, so a code blue is not necessary.

A patient is on a continuous cardiac monitoring, which begins to sound its alarm. Nurse Natividad sees no electrocardiogram complexes on the screen. The first action of the nurse is to:

A. Check the patient status and lead placement

B. Press the recorder button on the ECG console

C. Call MD

D. Call a code blue

B. Inhale deeply and cough forcefully every 1 to 3 seconds

Cough CPR is described as a "resuscitation technique" that can convert ventricular tachycardia to sinus rhythm person before cardiac arrest can keep conscious until help arrives. However, this technique is not always effective and should only be used as a last resort.

Lying down flat in bed helps to reduce the patient's heart rate and blood pressure, which can help to stabilize their condition. It also helps to conserve energy and reduce the risk of fainting.

A. Deep breathing can help to calm the patient, but it will not stop an episode of ventricular tachycardia.

C. Lie down flat in bed: This position may make it more difficult for the patient to breathe and may not be effective in terminating VT.

D. Removing metal jewelry is not necessary and may cause unnecessary anxiety for the patient.

A nurse is caring for a patient with unstable ventricular tachycardia. The nurse instructs the patient to do which of the following if prescribed, during an episode of ventricular tachycardia?

A. Breathe deeply, regularly, and easily

B. Inhale deeply and cough forcefully every 1 to 3 seconds

C. Lie down flat in bed

D. Remove any metal jewelry

A. Limiting movement and abduction of the right arm

The catheter is inserted through the right subclavian vein and then threaded into the right atrium or ventricle of the heart. Abduction of the right arm can put tension on the catheter and dislodge it from the heart.

B. Limiting movement and abduction of the left arm: This is not necessary as the catheter is inserted into the right subclavian vein.

C. Assisting the patient to get out of bed and ambulate with a walker: This can be done later in the day, once the catheter is more secure.

D. Having the physical therapist do active range of motion to the right arm: This should not be done until the catheter is fully healed, which usually takes about 6 weeks.

Nurse Villarama is caring for a patient immediately after insertion of a permanent pacemaker via the right subclavian vein. The nurse takes care to avoid dislodging the pacing catheter by

A. Limiting movement and abduction of the right arm

B. Limiting movement and abduction of the left arm'

C. Assisting the patient to get out of the bed and ambulate with a walker.

D. Having the physical therapist do active range of motion to the right arm

D. Moving to a cooler climate is needed

Raynaud's disease is a condition characterized by episodes of vasospasm, or the narrowing of blood vessels, in the fingers and toes. This vasospasm is triggered by exposure to cold temperatures or emotional stress. While moving to a warmer climate can help to reduce the frequency and severity of Raynaud's attacks, it is not a definitive treatment and may not be feasible for all patients.

A. Smoking can worsen Raynaud's symptoms by constricting blood vessels.

B. Caffeine is a stimulant that can constrict blood vessels and trigger Raynaud's attacks.

C. Nifedipine is a calcium channel blocker that can help to relax blood vessels and reduce the frequency and severity of Raynaud's attacks.

Nurse Tionko has given instructions to the patient with Raynaud's disease. The nurse determines that the patient needs further reinforcement if the patient states that

A. Smoking cessation is important

B. Sources of caffeine should be eliminated from the diet

C. Taking nifedipine as prescribed will decrease vessel spasm D. Moving to a cooler climate is needed

D. Taking the BP within 15 minutes after nicotine or caffeine ingestion

Nicotine and caffeine are vasoconstrictors, meaning they cause blood vessels to narrow. This can temporarily elevate BP, leading to inaccurate readings. It is recommended to wait at least 30 minutes after consuming nicotine or caffeine before taking BP.

A. Seating the patient with arm bared, supported at heart level ensures proper positioning of the limb and minimizes venous congestion, which can affect BP readings.

B. Measuring the BP after the patient has been seated quietly for 5 minutes will still yield inaccurate results.

C. Using a cuff with a rubber bladder that encircles at least 80% of the limb: An appropriately sized cuff ensures accurate pressure distribution and avoids overestimation of BP.

Nurse Cabezon is assessing the BP of a patient diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following?

A. Seating the patient with arm bared, supported at heart level

B. Measuring the BP after the patient has been seated quietly for 5 minutes

C. Using a cuff with a rubber bladder that encircles at least 80% of the limb

D. Taking the BP within 15 minutes after nicotine or caffeine ingestion

B. Hyperactive bowel sounds in the area

This is a nonspecific finding and can be caused by a variety of factors, including gas, intestinal obstruction, or inflammation. It is not directly related to the aneurysm itself.

A. Pulsatile abdominal mass is a common finding in patients with abdominal aortic aneurysms and is caused by the pulsating blood within the enlarged artery.

C. Systolic bruit over the area of the mass is a swooshing sound heard over the area of the aneurysm and is caused by the turbulent flow of blood through the narrowed artery.

D. Subjective sensation of "heart beating" in the abdomen is a nonspecific finding and can be caused by a variety of factors, such as anxiety, gas, or intestinal hypermotility. It is not directly related to the aneurysm itself.

A nurse is assessing Mr. Vargas, a patient with abdominal aortic aneurysm. Which of the following assessment findings by the nurse is unrelated to the aneurysm?

A. Pulsatile abdominal mass

B. Hyperactive bowel sounds in the area

C. Systolic bruit over the area of the mass

D. Subjective sensation of "heart beating" in the abdomen

D. Has brown pigmentation surrounding it.

This pigmentation is caused by hemosiderin deposition, a result of the breakdown of red blood cells and its superficial position over arteries.

Venous ulcers develop as a consequence of chronic venous insufficiency. Arterial ulcers typically present as deep, "punched-out" wounds with well-defined edges and can be painful. Venous ulcers appear as shallow, irregularly shaped wounds with uneven edges.

A. A pale-colored base is more commonly seen in arterial ulcers, which are caused by a lack of blood flow to the area.

B. Is deep, with even edges: Deep, even edges are more commonly seen in pressure ulcers, which are caused by prolonged pressure on the skin.

C. Little granulation tissue is a sign of poor wound healing. Venous stasis ulcers are typically slow to heal due to the underlying venous insufficiency.

A patient is admitted with a venous stasis leg ulcer. The nurse notes that the ulcer:

A. Has pale-colored base

B. Is deep, with even edges

C. Has little granulation tissue

D. Has brown pigmentation surrounding it

C. Variant angina.

also known as Prinzmetal angina, is caused by vasospasms in the coronary arteries that can occur spontaneously and are not related to physical exertion or emotional stress. The pain is typically described as sharp and crushing, and it can occur in the same location each time (may be prolonged and more severe that also occurs at the same time each day).

A. Stable angina occurs with physical exertion or emotional stress goes away with rest or nitroglycerin. It only lasts for a few minutes.

B. Unstable angina is a more serious form of angina that is characterized by pain that is more frequent, prolonged, and severe than stable angina. The pain can also occur at rest and may not be relieved by nitroglycerin.

D. Non-anginal angina: doesn't exist

A patient with angina complains that the anginal pain is prolonged and more severe that also occurs at the same time each day, most often in the morning. On further assessment the nurse notes that the pain occurs in the absence of precipitating factors. This type of anginal pain is best described as

A. Stable angina

B. Unstable angina

C. Variant angina

D. Non-anginal angina