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Various nursing interventions and patient education related to the management of cardiovascular conditions, such as stable angina, myocardial infarction, chronic heart failure, raynaud's phenomenon, and peripheral artery disease. It addresses topics like medication administration, monitoring vital signs, identifying emergency situations, promoting lifestyle modifications, and providing patient education. The document highlights the nurse's role in assessing patient symptoms, implementing appropriate nursing actions, and collaborating with the healthcare team to optimize patient outcomes.
Typology: Exams
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When developing a health teaching plan for a 65-year-old patient with all these risk factors for coronary artery disease (CAD), the nurse will focus on the __________ - correct answer ✔✔low activity level the patient reports. To assist the patient with CAD to make the appropriate dietary changes, which of these nursing interventions will be most effective? - correct answer ✔✔Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible. The nurse is admitting a patient who is complaining of chest pain to the emergency department (ED). Which information collected by the nurse suggests that the pain is caused by an acute myocardial infarction (AMI)? - correct answer ✔✔The pain has persisted longer than 30 minutes. A patient is admitted to the ED after an episode of severe chest pain, and the physician schedules the patient for coronary angiography and possible percutaneous coronary intervention (PCI). The nurse prepares the patient for the procedure by explaining that it is used to ________________________ - correct answer ✔✔visualize any coronary artery blockages and dilate any obstructed arteries. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? - correct answer ✔✔The patient indicates that the pain is resolved after taking one sublingual nitroglycerin tablet. Which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest pain? - correct answer ✔✔ST-segment elevation When caring for a patient with ACS who has returned to the coronary care unit after having a PCI, the nurse obtains these assessment data. Which data indicate the need for immediate intervention by the nurse? - correct answer ✔✔Chest pain level 8 on a 10-point scale
In developing a teaching plan for a patient who has stable angina and is started on sublingual nitroglycerin (Nitrostat), the nurse identifies an expected patient outcome of - correct answer ✔✔identifying the need to call the emergency medical services (EMS) if chest pain persists 5 minutes after taking nitroglycerin. Which of these statements made by a patient after the nurse has completed teaching about the TLC diet indicates that further teaching is needed? - correct answer ✔✔"I will miss being able to eat peanut butter sandwiches." After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective? - correct answer ✔✔"It is important not to suddenly stop taking the atenolol." A patient who has had severe chest pain for the last 4 hours is admitted with a diagnosis of possible AMI. Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an MI? - correct answer ✔✔Troponin levels Nifedipine (Procardia) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that Procardia will ____________ - correct answer ✔✔decrease spasm of the coronary arteries. A patient with chronic stable angina is being treated with metoprolol (Lopressor). The nurse will suspect that the patient is experiencing a side effect of the metoprolol if __________________ - correct answer ✔✔the cardiac monitor shows a heart rate of 45. Nadolol (Corgard) is prescribed for a patient with angina. In evaluating the effectiveness of the drug, the nurse will monitor for _________________ - correct answer ✔✔ability to do daily activities without chest discomfort. A patient admitted to the coronary care unit (CCU) with an MI and frequent premature ventricular contractions (PVCs) has health care provider orders for continuous amiodarone infusion, IV nitroglycerin infusion, and morphine sulfate 2 mg IV every 10 minutes until there is relief of pain. The patient says, "This is the worst pain I have ever had. Am I going to die?" Based on these data, the nurse identifies a priority nursing diagnosis of ___________________ - correct answer ✔✔acute pain related to myocardial ischemia.
A patient with a non-ST segment elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? - correct answer ✔✔Heparin will prevent the development of clots in the coronary arteries. While admitting a patient with an AMI, which action should the nurse carry out first? - correct answer ✔✔Attach the cardiac monitor. The nurse administers IV nitroglycerin to a patient with an MI. In evaluating the effect of this intervention, the nurse should monitor for _______________ - correct answer ✔✔relief of chest discomfort. A patient with ST-segment elevation in several ECG leads is admitted to the ED and diagnosed as having an AMI. Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy? - correct answer ✔✔"What time did your chest pain begin?" Following an AMI, a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response, which of these assessment data would indicate that the exercise level should be decreased? - correct answer ✔✔Heart rate increases from 66 to 90 beats/min. During the administration of the fibrinolytic agent to a patient with an AMI, the nurse should stop the drug infusion if the patient experiences _______________ - correct answer ✔✔a decrease in level of consciousness. A patient is receiving fibrinolytic therapy 2 hours after developing an AMI. Which assessment information will be of most concern to the nurse? - correct answer ✔✔No change in the patient's chest pain Three days after an MI, the patient develops chest pain that radiates to the back and left arm and is relieved by sitting in a forward position. On auscultation of the patient's chest, the nurse would expect to hear a ____________ - correct answer ✔✔pericardial friction rub. After the nurse teaches a patient with chronic stable angina about how to use the prescribed nitrates, which statement by the patient indicates that the teaching has been effective? - correct answer ✔✔"I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."
Two days after having an MI, a patient tells the nurse, "I wish I had died when I had this heart attack. I won't be able to do anything now." The most appropriate nursing diagnosis is ___________________ - correct answer ✔✔situational low self-esteem related to perceived role changes. The nurse obtains the following data when caring for a patient who experienced an AMI 2 days previously. Which information is most important to report to the health care provider? - correct answer ✔✔The lungs have crackles audible to the midline. When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an AMI, the nurse will anticipate teaching the patient _______________ - correct answer ✔✔about the purpose of outpatient Holter monitoring. A few days after experiencing an MI, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which nursing intervention is appropriate to include in the nursing care plan? - correct answer ✔✔Allow the use of denial as a coping mechanism until the patient begins asking questions about the MI. When evaluating the outcomes of preoperative teaching with a patient scheduled for a coronary artery bypass graft (CABG) using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says, ________________ - correct answer ✔✔"I will have incisions in my leg where they will remove the vein." After having an AMI, a 62-year-old patient tells the nurse, "I guess having sex again will be too hard on my heart." The nurse's best response is ______________ - correct answer ✔✔"Sexual activity can be gradually resumed like other activity. A good comparison of energy expenditure is climbing two flights of stairs." Which of these nursing interventions included in the plan of care for a patient who had an AMI 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN? - correct answer ✔✔Administration of the ordered metoprolol (Lopressor) and aspirin A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports all the following symptoms to the nurse. Which is most important to communicate to the health care provider?
A patient who has chest pain is admitted to the ED, and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first? - correct answer ✔✔ECG For a patient who has been admitted the previous day to the coronary care unit with an AMI, the nurse will anticipate teaching the patient about _______________ - correct answer ✔✔when patient cardiac rehabilitation will begin. A patient with hyperlipidemia has a new order for the bile-acid sequestrant medication colesevelam (Welchol). Which nursing action is appropriate when giving the medication? - correct answer ✔✔Give the patient's other medications 2 hours after the Welchol. A patient who is being admitted to the emergency department with severe chest pain gives the following list of medications taken at home to the nurse. Which of the medications has the most immediate implications for the patient's care? - correct answer ✔✔sildenafil (Viagra) The nurse has just received change-of-shift report about these four patients. Which patient should the nurse assess first? - correct answer ✔✔A 51-year-old who has just returned to the unit after a coronary arteriogram and PCI A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to ________________ - correct answer ✔✔auscultate the lung sounds. A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a 5-pound weight gain in the last 3 days. The nurse's first action will be to _______________ - correct answer ✔✔assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring. During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates _____________ - correct answer ✔✔elevated right atrial pressure. The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best
indicator that the treatment has been effective is ____________________ - correct answer ✔✔decreased dyspnea with the head of the bed at 30 degrees. When the nurse is developing a teaching plan to prevent the development of heart failure in a patient with stage 1 hypertension, the information that is most likely to improve compliance with antihypertensive therapy is that _______________ - correct answer ✔✔hypertension eventually will lead to heart failure by overworking the heart muscle. A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to _______________ - correct answer ✔✔administer IV morphine sulfate 2 mg. Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the Nipride rate if the patient develops ____________ - correct answer ✔✔a systolic BP <90 mm Hg. A patient admitted to the hospital with an exacerbation of chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse can best document this assessment information as _______________ - correct answer ✔✔paroxysmal nocturnal dyspnea. During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is _________________ - correct answer ✔✔impaired skin integrity related to peripheral edema. The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient ________________ - correct answer ✔✔calls when the weight increases from 124 to 130 pounds in a week. When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such as ______________ - correct answer ✔✔positioning the patient in a high-Fowler's position with the feet horizontal in the bed.
When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include ________________ - correct answer ✔✔milk, yogurt, and other milk products. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin), hydrochlorothiazide (HydroDIURIL), and a potassium supplement. Appropriate instructions for the patient include _______________ - correct answer ✔✔notify the health care provider immediately if nausea or difficulty breathing occurs. The nurse identifies the collaborative problem of potential complication: pulmonary edema for a patient in ADHF. When assessing the patient, the nurse will be most concerned about ______________ - correct answer ✔✔an oxygen saturation of 88% on room air. While admitting an 80-year-old patient with heart failure to the medical unit, the nurse obtains the information that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." The nurse makes a note that discharge planning for the patient will need to include _____________ - correct answer ✔✔referral to a home health care agency. A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of heart failure. The patient data that will require the most immediate action by the nurse is if the patient's _________________ - correct answer ✔✔serum potassium level is 3.0 mEq/L after 1 week of therapy. Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about _______________ - correct answer ✔✔angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten). A 55-year-old patient with inoperable coronary artery disease and end-stage heart failure asks the nurse whether heart transplant is a possible therapy. The nurse's response to the patient will be based on the knowledge that ____________ - correct answer ✔✔candidacy for heart transplant depends on many factors. An outpatient who has developed heart failure after having an acute myocardial infarction has a new prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic. The assessment finding that will be of most concern to the nurse is that the patient ______________ - correct answer ✔✔has BP of 88/42.
An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is ______________ - correct answer ✔✔B-type natriuretic peptide (BNP). A patient with ADHF who is receiving nesiritide (Natrecor) asks the nurse how the medication will work to help improve the symptoms of dyspnea and orthopnea. The nurse's reply will be based on the information that nesiritide will ___________ - correct answer ✔✔dilate arterial and venous blood vessels, decreasing ventricular preload and afterload. A patient who is receiving dobutamine (Dobutrex) for the treatment of ADHF has all of the following nursing actions included in the plan of care. Which action will be best for the RN to delegate to an experienced LPN/LVN? - correct answer ✔✔Monitor the patient's BP every hour. A hospitalized patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about captopril, which statement by the patient indicates that teaching has been effective? - correct answer ✔✔"I will call for help when I need to get up to the bathroom." In analyzing a patient's electrocardiographic (ECG) rhythm strip, the nurse uses the knowledge that the time of the conduction of an impulse through the Purkinje fibers is represented by the __________________ - correct answer ✔✔PR interval. When needing to estimate the ventricular rate quickly for a patient with a regular heart rhythm using an ECG strip, the nurse will ______________ - correct answer ✔✔use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. A patient has a junctional escape rhythm on the monitor. The nurse would expect the patient to have a pulse rate of ____ beats/min. - correct answer ✔✔40- A patient who is complaining of a "racing" heart and nervousness comes to the emergency department. The patient's blood pressure (BP) is 102/68. The nurse places the patient on a cardiac monitor and obtains the following ECG tracing.
Which action should the nurse take next? - correct answer ✔✔Obtain further information about possible causes for the heart rate. A patient has a dysrhythmia that requires careful monitoring of atrial activity. Which lead will be best to use for continuous monitoring? - correct answer ✔✔MCL The nurse obtains a monitor strip on a patient admitted to the coronary care unit with a myocardial infarction and makes the following analysis: P wave not apparent; ventricular rate 162, R-R interval regular; PR interval not measurable; and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as _______________ - correct answer ✔✔ventricular tachycardia. The nurse determines that a patient has ventricular bigeminy when the rhythm strip indicates that ________________ - correct answer ✔✔every other QRS complex is wide and starts prematurely. A patient has a normal cardiac rhythm strip except that the PR interval is 0.34 seconds. The appropriate intervention by the nurse is to ________________ - correct answer ✔✔document the finding and continue to monitor the patient. A patient with diabetes mellitus is admitted unresponsive to the emergency department (ED). Initial laboratory findings are serum potassium 2.8 mEq/L (2.8 mmol/L), serum sodium 138 mEq/L ( mmol/L), serum chloride 90 mEq/L (90 mmol/L), and blood glucose 628 mg/dl (34.9 mmol/L). Cardiac monitoring shows multifocal PVCs. The nurse understands that the patient's PVCs are most likely caused by _______________ - correct answer ✔✔hypokalemia. The nurse reviews data from the cardiac monitor indicating that a patient with a myocardial infarction experienced a 50-second episode of ventricular tachycardia before a sinus rhythm and a heart rate of 98 were re-established. The most appropriate initial action by the nurse is to ________________ - correct answer ✔✔administer IV antidysrhythmic drugs per protocol. A patient experiences dizziness and shortness of breath for several days. During cardiac monitoring in the ED, the nurse obtains the following ECG tracing. The nurse interprets this cardiac rhythm as _______________ - correct answer ✔✔third-degree AV block.
A patient with myocardial infarction develops symptomatic hypotension. The monitor shows a type 1, second-degree AV block with a heart rate of 30. The nurse administers IV atropine as prescribed. The nurse determines that the drug has been effective on finding a(n) _________________ - correct answer ✔✔increase in the patient's heart rate. A patient with dilated cardiomyopathy has an atrial fibrillation that has been unresponsive to drug therapy for several days. The nurse anticipates that further treatment of the patient will require ____________ - correct answer ✔✔anticoagulant therapy with warfarin (Coumadin). The nurse hears the cardiac monitor alarm and notes that the patient has a cardiac pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious with no pulse or respirations. After calling for assistance, the nurse should _______________ - correct answer ✔✔start basic cardiopulmonary resuscitation (CPR). During change-of-shift report, the nurse learns that a patient with a large myocardial infarction has been having frequent PVCs. When monitoring the patient for the effects of PVCs, the nurse will check the patient's _____________ - correct answer ✔✔apical radial heart rate. A patient who has been successfully resuscitated after developing ventricular fibrillation asks the nurse about what happened. The most appropriate response by the nurse is, _____________ - correct answer ✔✔"You had a serious abnormal heart rhythm, which treatment was able to reverse."
A patient with supraventricular tachycardia (SVT) is hemodynamically stable and requires cardioversion. The nurse will plan to _______________ - correct answer ✔✔administer a sedative before the procedure is begun. A patient's sinus rhythm rate is 62. The PR interval is 0.18 seconds at 1:00 AM, 0.20 seconds at 12:30 PM, and 0.23 seconds at 4:00 PM. Which action should the nurse take? - correct answer ✔✔Hold the ordered metoprolol (Lopressor) and call the health care provider. A patient develops sinus bradycardia at a rate of 32 beats/min, has a BP of 80/36 mm Hg, and is complaining of feeling faint. Which action should the nurse take? - correct answer ✔✔Obtain and apply the transcutaneous pacemaker (TCP). A 21-year-old college student arrives at the student health center at the end of the quarter complaining, "My heart is skipping beats." The nurse obtains an ECG and notes the presence of occasional PVCs. What action should the nurse take first? - correct answer ✔✔Question the patient about current stress level and coffee use. A 19-year-old student has a mandatory ECG before participating on a college swim team and is found to have sinus bradycardia, rate 52. BP is 114/54, and the student denies any health problems. What action by the nurse is appropriate? - correct answer ✔✔Allow the student to participate on the swim team. The nurse has received change-of-shift report about all of these patients on the telemetry unit. Which patient should the nurse see first? - correct answer ✔✔A patient whose ICD fired three times today who is scheduled for a dose of amiodarone (Cordarone) When analyzing the waveforms of a patient's ECG, the nurse will need to investigate further upon finding a _________ - correct answer ✔✔QRS interval of 0.14 second. When analyzing an ECG rhythm strip of a patient with a regular cardiac rhythm, the nurse finds there are 25 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ______. - correct answer ✔✔ 60 When a patient requires defibrillation, in which order will the nurse accomplish the following steps? - correct answer ✔✔1 Turn the defibrillator on.
2 Select the appropriate energy level 3 Place the paddles on the patient's chest. 4 Check the location of other personnel and call out "all clear." 5 Deliver the electrical charge. The nurse obtains a health history from a patient with a prosthetic mitral valve who has symptoms of infective endocarditis. Which question by the nurse is most appropriate? - correct answer ✔✔"Have you been to the dentist lately?" The health care provider writes the following admitting orders for a patient with suspected IE who has fever and chills: ceftriaxone (Rocephin) 1.0 g intravenous piggyback (IVPB) q12hr, acetylsalicylic acid (ASA) for temperature above 102° F (38.9° C), and blood cultures ∗ 2, complete blood cell count (CBC), and electrocardiogram (ECG). When admitting the patient, the nurse gives the highest priority to ____________ - correct answer ✔✔obtaining the blood cultures. During the assessment of a patient with IE, the nurse would expect to find _________ - correct answer ✔✔dyspnea and a dry, hacking cough. The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with IE based on the assessment finding of _____________ - correct answer ✔✔urine output less than 30 ml/hr. A patient hospitalized with a streptococcal infective endocarditis tells the nurse," I know that I need antibiotics, but I do not want to be hospitalized for very long." The nurse explains that _______________ - correct answer ✔✔the patient will be able to receive outpatient IV antibiotic therapy if complications such as heart failure do not develop. A patient hospitalized with IE develops sharp left flank pain and hematuria. The nurse notifies the health care provider, recognizing that these symptoms may indicate ______________ - correct answer ✔✔vegetative embolization. A patient is admitted to the hospital with possible acute pericarditis. The nurse will plan to teach the patient about the purpose of ______________ - correct answer ✔✔multiple ECGs.
To assess the patient with pericarditis for the presence of a pericardial friction rub, the nurse should _____________ - correct answer ✔✔place the diaphragm of the stethoscope at the lower left sternal border of the chest. Which of these assessment data obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider? - correct answer ✔✔Jugular vein distension (JVD) to the level of the jaw Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should _____________ - correct answer ✔✔note when Korotkoff sounds are audible during both inspiration and expiration. The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The most appropriate intervention by the nurse for this problem is to ______________ - correct answer ✔✔position the patient in Fowler's position, leaning forward on the overbed table. While obtaining an admission health history from a patient with possible rheumatic fever, which question will be most pertinent to ask? - correct answer ✔✔"Have you had a recent sore throat?" A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. An appropriate nursing diagnosis based on these findings is ______________ - correct answer ✔✔activity intolerance related to fatigue and arthralgia. The nurse establishes the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge concerning long-term management of rheumatic fever when a patient recovering from rheumatic fever says, _______________ - correct answer ✔✔"I will be immune to further episodes of rheumatic fever after this infection." The community health nurse involved in programs to prevent rheumatic fever knows that the most important intervention to decrease the incidence of the disease is ________________ - correct answer ✔✔teaching people to seek medical diagnosis and treatment for streptococcal pharyngitis.
Which assessment information obtained by the nurse for a patient with aortic stenosis would be most important to report to the health care provider? - correct answer ✔✔The patient complains of chest pain associated with ambulation. When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for ______________ - correct answer ✔✔dyspnea and hemoptysis. A 21-year-old woman is scheduled for an open mitral valve commissurotomy for treatment of mitral stenosis. When explaining the advantage of valve repair instead of valve replacement to the patient, the nurse will include the information that _____________ - correct answer ✔✔long-term anticoagulation is necessary after mechanical valve replacement. While caring for a patient with mitral valve prolapse with mild valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient tells the nurse she will _______________ - correct answer ✔✔discuss the diagnosis of mitral valve prolapse with the dentist. 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 ___________ - correct answer ✔✔promote rest to decrease myocardial oxygen demand. During postoperative teaching with a patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient regarding ______________ - correct answer ✔✔how to monitor anticoagulation therapy. A few days after an acute MI, a patient complains of stabbing chest pain that increases with deep breathing. Which action will the nurse take first? - correct answer ✔✔Auscultate the heart sounds. A patient who has had recent cardiac surgery develops pericarditis and complains of severe chest pain with deep breathing. Which of these ordered PRN medications should the nurse administer? - correct answer ✔✔Oral ibuprofen (Motrin) 800 mg Which information obtained by the nurse when assessing a patient admitted with mitral valve stenosis should be communicated to the health care provider immediately? - correct answer ✔✔The patient has crackles audible to the lung apices.
When caring for the patient with infective endocarditis of the tricuspid valve, the nurse will plan to monitor the patient for ____________ - correct answer ✔✔dyspnea. A patient who has developed acute pulmonary edema is hospitalized and diagnosed with dilated cardiomyopathy. Which information will the nurse plan to include when teaching the patient about management of this disorder? - correct answer ✔✔Notify the doctor about any symptoms of heart failure such as shortness of breath. The nurse is taking a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC); which information obtained by the nurse is most relevant? - correct answer ✔✔The patient's 29-year-old brother has had a sudden cardiac arrest. Heparin is prescribed for a patient who has dilated cardiomyopathy has been admitted to the hospital with fatigue and orthopnea. Which statement is appropriate for the nurse to use in patient teaching about anticoagulation therapy? - correct answer ✔✔"Heparin will help prevent blood clots from forming in your heart chambers." A patient with a history of a 4-cm abdominal aortic aneurysm is admitted to the emergency department with severe back pain and bilateral flank ecchymoses. The vital signs are blood pressure (BP) 90/58, pulse 138, and respirations 34. The nurse plans interventions for the patient based on the expectation that treatment will include ____________ - correct answer ✔✔immediate surgery. A 69-year old patient is admitted to the hospital for elective repair of an abdominal aortic aneurysm. The history includes hypertension for 25 years, hyperlipidemia for 15 years, and smoking for 50 years. The patient asks the nurse what caused the aneurysm. The nurse's best response includes the information that ______________ - correct answer ✔✔atherosclerotic plaques damage the artery and may lead to aneurysms. A patient has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining a nursing history from the patient, the nurse will ask the patient about _________ - correct answer ✔✔difficulty swallowing. Several hours following a surgical repair of an abdominal aortic aneurysm, the patient develops left flank pain and a urinary output of 20 ml/hr for 2 hours. The nurse notifies the health care provider and anticipates orders for a(n) _____________ - correct answer ✔✔blood urea nitrogen (BUN) and creatinine.
The nurse identifies a nursing diagnosis of risk for altered peripheral tissue perfusion related to bypass graft thrombosis for a patient following an abdominal aneurysm repair. An appropriate intervention to prevent this problem in the immediate postoperative period is to _______________ - correct answer ✔✔administer IV fluids at a rate to keep the arterial BP within a normal range. After repair of an abdominal aortic aneurysm, the nurse notes that the patient does not have popliteal, posterior tibial, or dorsalis pedis pulses. The legs are cool and mottled. Which action is appropriate for the nurse to take first? - correct answer ✔✔Review the preoperative assessment form for data about the pulses. A nursing action that is indicated for the collaborative problem of potential complication: cardiac dysrhythmia in a patient who has had a repair of a descending thoracic aortic aneurysm is to ______________ - correct answer ✔✔titrate oxygen to keep O2 saturation greater than 90%. When the nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, the information that is most significant when the nurse is assessing for the return of peristalsis is ______________ - correct answer ✔✔passing of flatus with ambulation. A 72-year-old patient is hospitalized for an aortic dissection of the abdominal aorta that stabilizes with treatment. The nurse develops a teaching plan for the patient's discharge that includes information about _______________ - correct answer ✔✔the use of antihypertensive medications to lower the risk of further dissection or bleeding. A patient recovering on a general surgical unit from an aortic valve replacement 1 week ago develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the health care provider and _______________ - correct answer ✔✔keep the patient in bed in the supine position. During an assessment of a 63-year-old patient at the clinic, the patient says, "I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." The nurse should _____________ - correct answer ✔✔attempt to palpate the dorsalis pedis and posterial tibial pulses. The nurse performing an assessment with a patient who has chronic peripheral arterial disease (PAD) of the legs would expect to find _______________ - correct answer ✔✔prolonged capillary refill.
The nurse identifies the nursing diagnosis of ineffective peripheral perfusion related to decreased arterial blood flow for a patient with chronic PAD. In evaluating the patient outcomes following patient teaching, the nurse determines a need for further instruction when the patient says, ______________ - correct answer ✔✔"I will use a heating pad on my feet at night to increase the circulation and warmth in my feet." A patient who has had a femoral-popliteal bypass graft to the right leg is being cared for on the surgical unit. Which action by an LPN/LVN caring for the patient requires the RN to intervene? - correct answer ✔✔The LPN/LVN has the patient sit in a bedside chair for 90 minutes. A 36-year-old patient who has a history of thromboangiitis obliterans (Buerger's disease) is admitted to the hospital with a gangrenous lesion of the right small toe. When the nurse is planning expected outcomes for the patient, which outcome has the highest priority for this patient? - correct answer ✔✔Cessation of smoking After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which behavior by the patient indicates that the teaching has been effective? - correct answer ✔✔The patient exercises indoors during the winter months. A patient admitted to the hospital with DVT has health care provider's orders for bed rest with the feet elevated. The best method for the nurse to use in elevating the patient's feet is to _____________ - correct answer ✔✔put one pillow under the thighs and two pillows under the lower legs. The health care provider orders a continuous IV heparin infusion for a patient with swelling and pain of the upper leg caused by a DVT. While the patient is receiving the heparin infusion, the nurse should _____________ - correct answer ✔✔avoid any IM medications to prevent localized bleeding. The nurse has identified the collaborative problem of potential complication: pulmonary embolism for a patient with left-calf DVT. Which nursing action is appropriate to include in the plan of care? - correct answer ✔✔Maintain bed rest as ordered. A patient with a DVT is started on IV heparin and oral warfarin (Coumadin). The patient asks the nurse why two medications are necessary. The nurse's best response to the patient is, __________ - correct answer ✔✔"The heparin will work immediately, but the Coumadin takes several days to have an effect on coagulation."
The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for DVT. The nurse determines that additional teaching is needed when the patient says, _________________ __ - correct answer ✔✔"I should change my diet to include more green, leafy vegetables." A 42-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Before discharging the patient, the nurse teaches the patient that ___________ - correct answer ✔✔compression stockings should be applied before getting out of bed. In planning care for a patient with a venous stasis ulcer on the right lower leg, the nurse understands that the most important intervention in promoting healing of the ulcer is - correct answer ✔✔application of external compression to the lower leg. A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of these statements by the patient is most consistent with the diagnosis? - correct answer ✔✔"I can't get my shoes on at the end of the day." Which of these nursing actions in the care plan for a patient who had a repair of an abdominal aortic aneurysm 5 days previously is most appropriate for the nurse to delegate to an experienced nursing assistant? - correct answer ✔✔Assist the patient in using a pillow to splint while coughing. Which statement by a patient who is being discharged 5 days after an abdominal aortic aneurysm repair and graft indicates that the discharge teaching has been effective? - correct answer ✔✔"I will tell my dentist about this surgery the next time I have an appointment." A patient with PAD has a new prescription for clopidogrel (Plavix). Which information should the nurse include when teaching the patient about this medication? - correct answer ✔✔"Call if you notice that your stools are black or have blood in them." A patient who is seen in the clinic tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud's phenomenon. The nurse will anticipate teaching the patient about tests for ______________ - correct answer ✔✔immune disorders.
While working in the outpatient clinic, the nurse notes that the chart states that a patient has intermittent claudication. Which of these statements by the patient would be consistent with this information? - correct answer ✔✔"My legs cramp whenever I walk more than a block." When developing a teaching plan for a patient newly diagnosed with PAD, which information should the nurse include? - correct answer ✔✔"It is important to try to stop smoking." When assessing a patient with possible PAD, the nurse obtains a brachial BP of 140/80 and an ankle pressure of 110/70. The nurse calculates the patient's ankle-brachial index (ABI) as ______. - correct answer ✔✔0.78 or 0.