EXAM 3 Flashcards
(134 cards)
1
Q
What is the proper assessment technique when the patient is in respiratory distress?
A
Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment
2
Q
Physical examination technique for respiratory: thorax and lungs?
A
Inspection
Palpation
Percussion
Auscultation
3
Q
When the patient is going to have a thoracentesis, what is the proper position?
A
upright with elbows on an overbed table and feet supported.
4
Q
This lung sound is low-pitched, bubbling sounds usually heard on inspiration
A
crackles
5
Q
This lung sound is high-pitched sounds and they can be heard during the expiratory or inspiratory phase of the respiratory cycle
A
wheezing
6
Q
This lung sound have grating sounds that are usually heard during both inspiration and expiration.
A
pleural friction rub
7
Q
discontinuous, high-pitched sounds of short duration heard on inspiration
A
fine crackles
8
Q
long-duration, discontinuous, low-pitched sounds during inspiration.
A
coarse crackles
9
Q
Which sound is likely heard in the early phase of heart failure?
A
fine crackles
10
Q
low pitched sound heard over normal lungs
A
resonance
11
Q
loud, lower pitched sound than normal heard over hyperinflated lungs, such as COPD and acute asthma
A
hyperresonance
12
Q
medium-pitched over areas of solid & lung tissue, fluids in the pleural space
A
dullness
13
Q
How should the nurse assess for tactile fremitus?
A
the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as “99.”
14
Q
isolation precaution for tuberculosis
A
Airborne- N95 mask, HEPA masks
Negative airflow (6-12 hours)
Private room
15
Q
Diagnostics for tuberculosis
A
- Positive if greater than 15mm in duration in low risk individuals
- Read 48 to 72hours
- Two step testing recommended for health care workers
- Two step testing ensures future positive results accurately interpreted
- Chest X-ray
16
Q
Four drug regimen associated with TB
A
Isoniazid
Rifampin
Pyrazinamide
Ethambutol
17
Q
What causes pneumothorax?
A
- caused by air entering pleural cavity
- positive pressure in cavity causes lung to partially or fully collapse
- should be suspected after any trauma to chest wall
18
Q
Differentiate open variation and closed variation
A
Open variation- air enters through an opening in the chest wall
Closed variation- no external wound
19
Q
Symptoms associated with Pneumothorax
A
Mild tachycardia and dyspnea→ severe respiratory distress
Absent breath sounds over affected area
20
Q
Differentiate the two types of asthma
A
Asthma exacerbation and Asthma-COPD
21
Q
precipitating factors and symptoms during exacerbation of asthma
A
causes allergies: house dust, pet allergens, smokes, pollens
symptoms: sneezing, inflammatory response, congestions
22
Q
Symptoms of pulmonary embolism
A
Dyspnea is most common
Mild to moderate hypoxemia
Tachypnea, cough, chest pain, hemoptysis, crackles, wheezing, fever, accentuation of the pulmonic heart sound, tachycardia, and syncope
Massive emboli can cause mental status, hypotension, and feeling of impending doom
23
Q
Proper tracheostomy care
A
Explain procedure
Use tracheostomy care kit
Place patient semi fowler position
Assemble needed materials on beside next to the patient
wash hands. Put PPE
auscultate chest sounds
Open sterile technique, pour sterile H2O or normal saline
If present, remove the inner cannula.
Replace a disposable inner cannula with new cannula
Remove dried secretions from stoma 4x4
Place dressing around tube
Change tracheostomy tapes, using 2 person change technique
Some patients prefer tracheostomy tape
Repeat care 3 times/ day as needed.
24
Q
Know the effects of smoking on cilia
A
Smoking damages and eventually destroys these cilia. When the cilia become less effective at keeping the lungs clear, smokers may develop a habitual cough as they attempt to remove the mucus from their lungs. Smokers are at increased risk of contracting pneumonia and other respiratory infections.
25
Differentiate bronchial, vesicular, and bronchovesicular breath sounds
Bronchial- loud, high pitched sounds that resemble air blowing through a hollow pipe
Vesicular- soft, low-pitched, gentle, rustling sounds. Heard over the lung areas except the major bronchi
Bronchovesicular- medium pitch and intensity and are heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae
26
Respiratory allergy teaching include to AVOID?
- house dust
- dust mites
- pet allergens
- mold spores
- pollens
- smoke
27
Types of medications that:
Bind with H1, receptors on target cells, blocking histamine binding.
Relieves acute symptoms of allergic response (itching, sneezing, rhinorrhea)
Antihistamines
28
Types of medications that:
Stimulates adrenergic receptors on blood vessels
Promotes vasoconstriction, reduces nasal congestion
Decongestants
29
Types of medications that:
Blocks nasal cholinergic receptors
Reducing nasal secretions in the common cold and nonallergic rhinitis
Anticholinergics
30
Types of medications that:
makes breathing easier by relaxing the muscles in the lungs and widening the airways; Used to treat long-term conditions such as asthma
Bronchodilators
31
Priority decision for treatment of respiratory infection
Treatment with antiviral medication should be started as soon as possible.
temporary relief of symptoms. Rest, hydration, decongestant, acetaminophen for headaches, pain, and aches
32
How much increase intake of fluids for a patient with pneumonia?
Increase fluid intake at least 3L/ day
33
Signs of flail chest include?
Rapid, shallow respirations
Tachycardia
Patient moves air poorly
Movement of thorax is asymmetric and uncoordinated
Patient may also attempt to splint the chest to assist with breathing
Observation of abnormal thoracic cavity movements
Palpitation for crepitus near rib fractures and chest X-ray all assist in the diagnosis
34
List the chambers of the chest tube
Collection chamber
Water seal chamber
Suction control chamber
35
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
a. Ask the patient to lie down to complete a full physical assessment.
b. Briefly ask specific questions about this episode of respiratory distress.
c. Complete the admission database to check for allergies before treatment.
d. Delay the physical assessment to first complete pulmonary function tests.
b
36
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
a. High-Fowler’s position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table
d
37
A diabetic patient’s arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3– 18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure
b
38
On auscultation of a patient’s lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes
a
39
The nurse palpates the posterior chest while the patient says “99” and notes absent fremitus. Which action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally.
d
40
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient’s lungs, which finding would the nurse most likely hear?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous, high-pitched sounds of short duration during inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
c
41
The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to 88% while the patient is ambulating. What is the priority action of the nurse?
a. Notify the health care provider.
b. Administer PRN supplemental O2.
c. Document the response to exercise.
d. Encourage the patient to pace activity
b
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental O2 when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.
42
The nurse observes a student who is listening to a patient’s lungs. Which action by the student indicates a need to review respiratory assessment skills?
a. The student compares breath sounds from side to side at each level.
b. The student listens during the inspiratory phase, then moves the stethoscope.
c. The student starts at the apices of the lungs, moving down toward the lung bases.
d. The student instructs the patient to breathe slowly and deeply through the mouth.
b
43
A patient admitted to the emergency department complaining of sudden onset shortness of breath is diagnosed with a possible pulmonary embolism. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?
a. Ensure that the patient has been NPO.
b. Start an IV so contrast media may be given.
c. Inform radiology that radioactive glucose preparation is needed.
d. Instruct the patient to expect to inspire deeply and exhale forcefully.
b
Spiral computed tomography scans are the most commonly used test to diagnose pulmonary emboli and contrast media may be given IV. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography scans are most useful in determining the presence of malignancy and a radioactive glucose preparation is used. For spirometry, the patient is asked to inhale deeply and exhale as long, hard, and fast as possible.
44
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use?
a. “I have not had any acute asthma attacks during the past year.”
b. “I became short of breath an hour before coming to the hospital.”
c. “I’ve been taking Tylenol 650 mg every 6 hours for chest wall pain.”
d. “I’ve been using my albuterol inhaler more frequently over the last 4 days.”
d
The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider if this occurs. The other data do not indicate any need for additional teaching.
45
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?
a. Allergy to shellfish c. Respiratory rate of30
b. Apical pulse of 104 d. O2 saturation of 90%
a
46
After the nurse has received a change-of-shift report, which patient should the nurse assess first?
a. A patient with pneumonia who has crackles in the right lung base
b. A patient with chronic bronchitis who has a low forced vital capacity
c. A patient with possible lung cancer who has just returned after bronchoscopy
d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing
c
Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.
47
A patient is scheduled for a computed tomography (CT) scan of the chest with contrast media. Which assessment findings should the nurse report to the health care provider before the patient goes for the CT (select all that apply)?
a. Allergy to shellfish
b. Patient reports claustrophobia
c. Elevated serum creatinine level
d. Recent bronchodilator inhaler use
e. Inability to remove a wedding band
a, c
48
```
The patient is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas exchange in the lung and tissue oxygenation?
Thoracentesis
Bronchoscopy
Arterial blood gases
Pulmonary function tests
```
ABG's
Arterial blood gases are used to assess the efficiency of gas exchange in the lung and tissue oxygenation as is pulse oximetry. Thoracentesis is used to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication into the pleural space. Bronchoscopy is used for diagnostic purposes, to obtain biopsy specimens, and to assess changes resulting from treatment. Pulmonary function tests measure lung volumes and airflow to diagnose pulmonary disease, monitor disease progression, evaluate disability, and evaluate response to bronchodilators.
49
```
The nurse is caring for a patient who had abdominal surgery yesterday. Today the patient’s lung sounds in the lower lobes are diminished. The nurse knows this could be related to the occurrence of
pain.
atelectasis.
pneumonia.
pleural effusion.
```
atelectasis
50
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider?
a. Respirations are 36 breaths/min.
b. Anterior-posterior chest ratio is 1:1.
c. Lung expansion is decreased bilaterally.
d. Hyperresonance to percussion is present.
a
The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of O2 or medications. The other findings are common chronic changes occurring in patients with COPD.
51
A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats, the nurse will anticipate that the patient may require
a. emergent cardioversion.
b. a cardiac catheterization.
c. hourly blood pressure (BP) checks.
d. electrocardiographic (ECG) monitoring.
d
52
The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy 74-yr-old patient who is having an annual physical examination. What finding is of most concern to the nurse?
a. A right bundle-branch block.
c. The QRS duration is 0.13 seconds.
b. The PR interval is 0.21 seconds.
d. The heart rate (HR) is 41 beats/min.
d
53
During a physical examination of an older patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The best follow-up action for the nurse to take will be to
a. ask about risk factors for atherosclerosis.
b. determine family history of heart disease.
c. assess for symptoms of left ventricular hypertrophy.
d. auscultate carotid arteries for the presence of a bruit.
c
54
To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
a. diaphragm of the stethoscope with the patient lying flat.
b. bell of the stethoscope with the patient in the left lateral position.
c. diaphragm of the stethoscope with the patient in a supine position.
d. bell of the stethoscope with the patient sitting and leaning forward.
b
55
To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory test result will the nurse plan to review?
a. Troponin
c. Low-density lipoprotein (LDL)
b. Homocysteine (Hcy)
d. B-type natriuretic peptide (BNP)
d
56
While doing the hospital admission assessment for a thin older adult, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take next?
a. Teach the patient about aneurysms.
b. Notify the hospital rapid response team.
c. Instruct the patient to remain on bed rest.
d. Document the finding in the patient chart.
d
57
A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that
a. it will be important not to move at all during the procedure.
b. monitored anesthesia care will be provided during the procedure.
c. a flushed feeling may be noticed when the contrast dye is injected.
d. arterial pressure monitoring will be required for 24 hours after the test.
c
58
The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD) when lying flat in bed. Which follow-up action should the nurse take next?
a. Obtain vital signs, including oxygen saturation.
b. Have the patient perform the Valsalva maneuver.
c. Document this JVD finding in the patient’s record.
d. Observe for JVD with the patient elevated 45 degrees.
d
59
The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
a. connect the recorder to a computer once daily.
b. exercise more than usual while the monitor is in place.
c. remove the electrodes when taking a shower or tub bath.
d. keep a diary of daily activities while the monitor is worn.
d
60
When auscultating over the patient’s abdominal aorta, the nurse hears a loud humming sound. The nurse documents this finding as a
a. thrill. c. murmur.
b. bruit. d. normal finding.
b
61
The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The laboratory test result most helpful in indicating myocardial damage will be
a. myoglobin. c. homocysteine (Hcy)
b. troponins T and I. d. creatine kinase-MB (CK-MB).
b
62
When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To acquire more information about the murmur, which action will the nurse take?
a. Palpate the peripheral pulses.
b. Determine the timing of the sound.
c. Find the point of maximal impulse.
d. Compare apical and radial pulse rates.
b
63
The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth intercostal space and midclavicular line. How will the nurse record this information?
a. Systolic murmur heard at mitral area
b. Systolic murmur heard at Erb’s point
c. Diastolic murmur heard at aortic area
d. Diastolic murmur heard at the point of maximal impulse
a
64
A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse
a. presses on the skin over the tibia for 10 seconds to check for edema.
b. palpates both carotid arteries simultaneously to compare pulse quality.
c. documents a murmur heard along the right sternal border as a pulmonic murmur.
d. places the patient in the left lateral position to check for the point of maximal impulse.
b
65
Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?
a. Insert an IV catheter.
b. Administer oral sedative medications.
c. Teach the patient about the procedure.
d. Confirm that the patient has been fasting.
c
66
Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be important to report to the health care provider before the MRI?
a. The patient has an allergy to shellfish.
b. The patient has a history of atherosclerosis.
c. The patient has a permanent cardiac pacemaker.
d. The patient took the prescribed heart medications today.
c
MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information does not affect whether or not the patient can have an MRI.
67
When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse?
a. Patient complaint of feeling tired
b. Sinus tachycardia at a rate of 110 beats/min
c. Inversion of T waves on the electrocardiogram
d. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg
c
68
thin, inner lining of the heart is called?
endocardium
69
muscle layer of the heart
myocardium
70
fibro serous sac covering the heart
pericardium
71
space between the pericardial layers
pericardial space
72
outer layer of the heart
epicardium
73
contraction of heart muscle, results in ejection of blood from the ventricles is called
systole
74
relaxation of the myocardium is called?
diastole
75
volume of blood in the ventricles at the end of diastole, before the next contraction
preload
76
peripheral resistance against which the left ventricle must pump
afterload
77
force generated atria during contraction
atrial kick
78
Modifiable risk factors for MI include? What risk factor is unmodifiable?
Abnormal lipids, obesity, psychosocial factors, consumption of fruit/veggie, smoking, ETOH,
regular physical activity, stress, high blood pressure (hypertension), race, gender, family hx
Diabetes Mellitus is unmodifiable
79
what are 2 MI Indicators
elevated troponin and CK MB
80
What is a heart failure indicator
elevated BNP
81
Inflammation or atherosclerosis indicator
elevated CRP
82
Know the direction of blood flow through the heart
A. Deoxygenated blood: inferior/superior vena cava and coronary sinus to the right atrium
a. Superior vena cava returns blood from the head, neck, and arms
b. Inferior vena cava returns blood from the lower part of the body
B. Right atrium: blood flow from right atrium to the tricuspid valve to the right ventricle
C. Right ventricle: pumps blood through the pulmonic valve and pulmonary artery and lungs
D. Oxygenated blood: flows from lungs to the pulmonary veins to the left atrium
E. Left atrium: pumps blood through the mitral valve to the left ventricle
F. Left ventricle: blood flows through aortic valve to aorta to systemic circulation
83
Know the Direction of electrical cycle
Atria AV node (through intermodal pathways) Bundle of His left/right bundle branches
(left has two divisions- anterior & posterior) Purkinje fibers (walls of ventricles)
84
begins with firing of SA node and depolarization of atria
P wave
85
depolarization from AV node and depolarization of ventricles
QRS complex
86
repolarization of the ventricles
T wave
87
repolarization of Purkinje fibers or hypokalemia
U wave
88
time it takes for the impulse to travel from one area to another
PR, QRS, QT intervals
89
bruit or thrill?
| abnormal flow causes a buzzing or humming sound (hear)
bruit
90
bruit or thrill?
| palpable vibration of vessel or chest wall (feel)
thrill
91
How should the nurse assess for bruits?
bell of the stethoscope placed over the vessel
92
How should the nurses auscultate murmur?
Using the bell of the stethoscope you’ll listen over the mitral valve area listening for turbulent sounds occurring between normal heart sounds.
If heard, are graded on a 6 point Roman numeral scale of loudness and recorded as a ratio.
o I/IV- indicated murmur is barely audible with stethoscope, heard only a in quiet room
o VI/VI- indicates murmur that can be heard with a stethoscope lifted of the chest wall
93
Differentiate S1-S4?
| associated with closure of the tricuspid and mitral valve (soft lubb sound) signals beginning of systole
S1
94
Differentiate S1-S4?
| associated with closure of the aortic and pulmonic valves (sharp dupp sound) signals beginning of diastole
S2
95
Differentiate S1-S4?
| low intensity vibration of the ventricular walls (heard in early diastole) aka ventricular gallop
S3
96
Differentiate S1-S4?
| low frequency vibration caused by the atrial contraction (heard in late diastole) aka atrial gallop
S4
97
What part of the stethoscope?
| used for higher pitched sounds (normal heart sounds or breath sounds)
diaphragm
98
What part of the stethoscope?
| used for detecting lower pitch sounds ( heart murmurs)
bell
99
Which valves are the loudest at the base?
AORTIC AND PULMONIC
100
Which valves are the loudest at the apex?
TRICUSPID AND MITRAL
101
Differentiate stenosis or regurgitation
| back flow of blood due to inadequate valve function
regurgitation
102
Differentiate stenosis or regurgitation
| hardening of the arteries
stenosis
103
CARDIAC MEDS
Aspirin
- Antipyretic = fever
- Analgesics = pain
- Anticoagulant = clots
- Anti-inflammatory = inflammation
104
Know how to calculate MAP
Mean arterial pressure: to confirm adequate perfusion
((2 x diastole) + systole) / 3 MAP = (SBP + 2 DBP) / 3
Multiply diastolic pressure by 2
Add the systolic
Divide by 3
MINIMAL TISSUE PERFUSION >/= 60
BP 140 / 90
2 x 90 = 180 180 + 140 = 320 320 / 3 = 106.7
105
Right-side heart failure (systemic) include?
a. Edema in the legs, increased weight, ascites
b. Hepatomegaly and splenomegaly
c. JVD distention and prominent pulsations of the neck veins
106
Left-side heart failure( (pulmonic) include?
a. S3 (ventricular gallop) present
b. Hypoxia and confusion, restlessness, tachypnea, orthopnea
c. Coughing, pulmonary congestion, dyspnea at night
107
What is a holter monitor and what is it used for?
uses electrodes and a recording device to track your heart's rhythm for 24 to 72 hours.
a doctor can print an electrocardiogram strip using the data on the recording device to see
your heart's rhythm during the period you wore the monitor.
108
Review 5 P’s of ischemia
pain, paresthesia, pallor, pulselessness, and poikilothermia -late stages of compartment syndrome
109
a syndrome in which a sudden rise in BP is associated with a severe headache, nausea, vomiting, seizures, confusion, and coma is called?
hypertensive encephalopathy
110
The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.” The nurse will need to call the health care provider about the
a. postoperative patient with a BP of 116/42 mm Hg.
b. newly admitted patient with a BP of 150/87 mm Hg.
c. patient with left ventricular failure who has a BP of 110/70 mm Hg.
d. patient with a myocardial infarction who has a BP of 140/86 mm Hg.
ANS: A
The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient in answer 3 is 67. The MAP in the other three patients is higher than 70 mm Hg.
111
When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider?
a. The patient’s pedal pulses are +1.
b. The patient is allergic to shellfish.
c. The patient had a heart attack 1 year ago.
d. The patient has not eaten anything today.
ANS: B
The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications such as corticosteroids and antihistamines before the angiogram. The other information is also communicated to the health care provider but will not require a change in the usual pre cardiac catheterization orders or medications.
112
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first?
a. Start an IV line.
c. Place the patient on NPO status.
b. Start O2 per nasal cannula.
d. Give lorazepam (Ativan) 1 mg IV.
ANS: C
The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure.
113
The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP?
a. Teaching a patient about exercise electrocardiography
b. Attaching ECG monitoring electrodes after a patient bathes
c. Checking the catheter insertion site for a patient who is recovering from a coronary angiogram
d. Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram
ANS: B
UAP can be educated in standardized lead placement for ECG monitoring. Assessment of patients who have had procedures where airway maintenance (transesophageal echocardiography) or bleeding (coronary angiogram) is a concern must be done by the registered nurse (RN). Patient teaching requires RN level education and scope of practice.
114
The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which laboratory result is most important to communicate as soon as possible to the health care provider?
a. High troponin I level
b. Increased triglyceride level
c. Very low homocysteine level
d. Elevated high-sensitivity C-reactive protein level
ANS: A
The elevation in troponin I indicates that the patient has had an acute myocardial infarction. Further assessment and interventions are indicated. The other laboratory results are indicative of increased risk for coronary artery disease but are not associated with acute cardiac problems that need immediate intervention
115
Which instruction by the nurse is given to a patient who is about to undergo Holter monitoring is most appropriate?
“You may remove the monitor only to shower or bathe.”
“You should connect the monitor whenever you feel symptoms.”
“You should refrain from exercising while wearing this monitor.”
“You will need to keep a diary of all your activities and symptoms.”
A Holter monitor is worn continuously for at least 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor.
116
```
The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. What allergy information is most important for the nurse to assess and document before this procedure?
Iron
Iodine
Aspirin
Penicillin
```
Iodine
The physician will usually use an iodine-based contrast to perform this procedure. Therefore it is imperative to know whether or not the patient is allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or penicillin will be secondary.
117
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The blood pressure of an older adult patient admitted with pneumonia is 160/70 mm Hg. What is an age-related change that contributes to this finding?
Stenosis of the heart valves
Decreased adrenergic sensitivity
Increased parasympathetic activity
Loss of elasticity in arterial vessels
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Loss of elasticity in arterial vessels
An age-related change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because of the increasing resistance to flow, pressure is increased within the blood vessel, and hypertension results. Valvular rigidity of aging causes murmurs, and decreased adrenergic sensitivity slows the heart rate. Blood pressure is not raised. Increased parasympathetic activity would slow the heart rate.
118
The nurse is providing care for a patient who has decreased cardiac output related to heart failure. What should the nurse recognize about cardiac output?
a. It is calculated by multiplying the patient’s stroke volume by the heart rate.
b. It is the average amount of blood ejected during one complete cardiac cycle.
c. It is determined by measuring the electrical activity of the heart and the patient’s heart rate.
d. It is the patient’s average resting heart rate multiplied by the patient’s mean arterial blood pressure.
a
Cardiac output is determined by multiplying the patient’s stroke volume by heart rate, thus identifying how much blood is pumped by the heart over a 1-minute period. Electrical activity of the heart and blood pressure are not direct components of cardiac output.
119
The nurse is performing an assessment for a patient with fatigue and shortness of breath. Auscultation of the heart reveals the presence of a murmur. What is this assessment finding indicative of?
Increased viscosity of the patient’s blood
Turbulent blood flow across a heart valve
Friction between the heart and the myocardium
A deficit in heart conductivity that impairs normal contractility
Turbulent blood flow across a heart valve
Turbulent blood flow across the affected valve results in a murmur. A murmur is not a direct result of variances in blood viscosity, conductivity, or friction between the heart and myocardium.
120
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A patient presents to the emergency department with reports of chest pain for 3 hours. What component of his blood work is most clearly indicative of a myocardial infarction (MI)?
CK-MB
Troponin
Myoglobin
C-reactive protein
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Troponin
Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity and specificity that exceed those of CK-MB and myoglobin. CRP levels are not used to diagnose acute MI.
121
When looking at the electrocardiogram (ECG) of the patient, the nurse knows that the QRS complex recorded on the ECG represents which part of the heart’s beat?
Depolarization of the atria
Repolarization of the ventricles
Depolarization from atrioventricular (AV) node throughout ventricles
The length of time it takes for the impulse to travel from the atria to the ventricles
Depolarization from atrioventricular (AV) node throughout ventricles
The QRS recorded on the ECG represents depolarization from the AV node throughout the ventricles. The P wave represents depolarization of the atria. The T wave represents repolarization of the ventricles. The interval between the PR and QRS represents the length of time it takes for the impulse to travel from the atria to the ventricles.
122
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In palpating the patient’s pedal pulses, the nurse determines the pulses are absent. What factor could contribute to this result?
Atherosclerosis
Hyperthyroidism
Arteriovenous fistula
Cardiac dysrhythmias
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Atherosclerosis can cause an absent peripheral pulse. The feet would also be cool and may be discolored. Hyperthyroidism causes a bounding pulse. Arteriovenous fistula gives a thrill or vibration to the vessel, although this would not be in the foot. Cardiac dysrhythmias cause an irregular pulse rhythm.
123
The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching?
a. “I will avoid adding salt to my food during or after cooking.”
b. “If I lose weight, I might not need to continue taking medications.”
c. “I can lower my blood pressure by switching to smokeless tobacco.”
d. “Diet changes can be as effective as taking blood pressure medications.”
c
Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (e.g., the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure–lowering medication.
124
The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-yr-old obese female patient admitted with heart failure. Which action by the UAP will require the nurse to intervene?
a. Waiting 2 minutes after position changes to take orthostatic pressures
b. Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second
c. Taking the blood pressure with the patient’s arm at the level of the heart
d. Taking a forearm blood pressure because the largest cuff will not fit the patient’s upper arm
b
The cuff should be deflated at a rate of 2 to 3 mm Hg per second. The arm should be supported at the level of the heart for accurate blood pressure measurements. Using a cuff that is too small causes a falsely high reading and too large causes a falsely low reading. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient.
125
A 44-yr-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After providing instruction, which statement by the patient indicates correct understanding?
a. “If I take this medication, I will not need to follow a special diet.”
b. “It is normal to have some swelling in my face while taking this medication.”
c. “I will need to eat foods such as bananas and potatoes that are high in potassium.”
d. “If I develop a dry cough while taking this medication, I should notify my doctor.”
d
Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced-sodium diet.
126
Which action will the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient?
a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
b. Have the patient sit in a chair with the feet flat on the floor.
c. Assist the patient to the supine position for BP measurements.
d. Obtain two BP readings in the dominant arm and average the results.
ANS: B
The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.
127
The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient?
a. Low dietary fiber intake
b. No regular physical exercise
c. Drinks a beer with dinner every night
d. Weight is 5 pounds above ideal weight
ANS: B
The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber, but increasing fiber alone will not prevent hypertension from developing. The patient’s alcohol intake is within guidelines and will not increase the hypertension risk.
128
3. Which action should the nurse take when giving the initial dose of oral labetalol to a patient with hypertension?
a. Encourage the use of hard candy to prevent dry mouth.
b. Teach the patient that headaches often occur with this drug.
c. Instruct the patient to call for help if heart palpitations occur.
d. Ask the patient to request assistance before getting out of bed.
ANS: D
Labetalol decreases sympathetic nervous system activity by blocking both - and -adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth, dehydration, and headaches are possible side effects of other antihypertensives.
129
After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been most effective?
a. The patient avoids eating nuts or nut butters.
b. The patient restricts intake of chicken and fish.
c. The patient drinks low-fat milk with each meal.
d. The patient has two cups of coffee in the morning.
ANS: C
For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not included in the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.
130
The nurse has just finished teaching a hypertensive patient about the newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed?
a. “The medication may not work well if I take aspirin.”
b. “I can expect some swelling around my lips and face.”
c. “The doctor may order a blood potassium level occasionally.”
d. “I will call the doctor if I notice that I have a frequent cough.”
ANS: B
Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.
131
Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension?
a. 98/56 mm Hg c. 128/92 mm Hg
b. 128/76 mm Hg d. 142/78 mm Hg
ANS: B
The 8th Joint National Committee’s recommended goal for antihypertensive therapy for a 30- to 59-yr-old patient with hypertension is a BP below 140/90 mm Hg. The BP of 98/56 mm Hg may indicate overtreatment of hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient’s treatment.
132
The nurse on the intermediate care unit received a change-of-shift report on four patients with hypertension. Which patient should the nurse assess first?
a. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain
b. 52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication
c. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL
d. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows microalbuminuria
ANS: A
The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention are needed. The symptoms of the other patients also show target organ damage but are not indicative of acute processes.
133
The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?
a. Serum creatinine of 2.8 mg/dL
c. Serum hemoglobin of 14.7 g/dL
b. Serum potassium of 4.5 mEq/L
d. Blood glucose level of 96 mg/dL
ANS: A
The elevated serum creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.
134
A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?
a. “Have you recently taken any antihistamines?”
b. “Have you consistently taken your medications?”
c. “Did you take any acetaminophen (Tylenol) today?”
d. “Have there been recent stressful events in your life?”
ANS: B
Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.
