LA#4 (Cardio) Chapters 34, 35, 36, 43 in Med Surg Flashcards
(147 cards)
1
Q
While monitoring a patient’s cardiac activity, the nurse recognizes that stimulation of which of the following is a normal physiological mechanism responsible for an increase in heart rate (HR) and force of cardiac contractions?
a. The vagus nerve
b. Baroreceptors in the aortic arch and carotid sinus
c. α-Adrenergic receptors in the vascular system
d. Chemoreceptors in the aortic arch and carotid body
A
ANS: D
Chemoreceptors located in the aortic arch and carotid body are capable of initiating changes in HR and arterial pressure in response to decreased arterial O2 pressure, increased arterial carbon dioxide pressure, and decreased plasma pH.
2
Q
While assessing a patient who has just arrived in the emergency department, the nurse notes a pulse deficit. Which of the following does the nurse anticipate that the patient may require?
a. Hourly blood pressure (BP) checks
b. A coronary arteriogram
c. Electrocardiographic (ECG) monitoring
d. A two-dimensional echocardiogram
A
ANS: C
Pulse deficit is a difference between simultaneously obtained apical and radial pulses and indicates that dysrhythmias might be detected with ECG monitoring.
3
Q
A patient has a BP of 142/84 mm Hg. The nurse will calculate and document the patient’s mean arterial pressure (MAP) as being which following amount?
a. 103 mm Hg
b. 113 mm Hg
c. 123 mm Hg
d. 131 mm Hg
A
ANS: A
MAP = Diastolic BP + 1/3 Pulse pressure.
4
Q
The nurse is monitoring a patient with possible coronary artery disease who is undergoing exercise (stress) testing on a treadmill. Which symptom has the most immediate implications for the patient’s care during the exercise testing?
a. BP rising from 134/68 to 150/80 mm Hg
b. HR increasing from 80 to 96 beats/min
c. Patient complaining of feeling short of breath
d. ECG indicating the presence of coronary ischemia
A
ANS: D
ECG changes associated with coronary ischemia (such as T-wave inversions and ST-segment depression) indicate that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately.
5
Q
During physical examination of a 56-year-old man, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the midclavicular line. What is the most appropriate interpretation of this finding?
a. The PMI is in the normal location.
b. The patient may have left ventricular hypertrophy.
c. The patient has age-related downward displacement of the heart.
d. The patient should be observed for signs of left atrial enlargement.
A
ANS: B
The PMI should be felt at the intersection of the fifth intercostal space and the midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy.
6
Q
To auscultate for extra heart sounds in the mitral area, with what part of the stethoscope will the nurse listen?
a. The bell of the stethoscope with the patient in the left lateral position
b. The diaphragm of the stethoscope with the patient in a reclining position
c. The diaphragm of the stethoscope with the patient lying flat on the left side
d. The bell of the stethoscope with the patient sitting and leaning to the right side
A
ANS: A
Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall.
7
Q
The standard orders on the cardiac unit state, “Notify the physician for MAP less than 70 mm Hg.” For which patient would the nurse call the physician?
a. The patient with left ventricular failure who has a BP of 110/70 mm Hg
b. The patient with a myocardial infarction who has a BP of 114/50 mm Hg
c. The postoperative patient with a BP of 116/42 mm Hg
d. The newly admitted patient with a BP of 122/60 mm Hg
A
ANS: C
The MAP is calculated using the formula MAP = (Diastolic BP + 1/3 Pulse Pressure). The MAP for the postoperative patient in C is 67 mm Hg. The MAP in the other three patients is higher than 70 mm Hg.
8
Q
During physical examination of a 72-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area just below the xiphoid process. How will the nurse interpret this finding?
a. Normal assessment data in a thin person
b. Sclerosis and inelasticity of the aorta
c. A possible abdominal aortic aneurysm
d. Evidence of elevated systemic arterial pressure
A
ANS: A
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals.
9
Q
A patient is scheduled for cardiac catheterization with coronary angiography. Before the test, about which of the following should the nurse inform the patient?
a. A catheter will be inserted into a vein in the arm or leg and advanced to the heart.
b. ECG monitoring will be required for 24 hours following the test to detect any dysrhythmias.
c. A feeling of warmth and a fluttering sensation may be experienced as the catheter is advanced.
d. Complications of the test include breaking of the catheter, air or blood embolism, and puncture of the ventricles.
A
ANS: C
A sensation of warmth or flushing is common when the iodine-based contrast material is injected, which can produce anxiety unless it has been discussed with the patient.
10
Q
Which of the following is a normal cardiac index (CI) assessment finding?
a. 2 L/min
b. 3 L/min/m2
c. 6 L/min
d. 8 L/min/m2
A
ANS: B
The normal range for a CI reading is 2.8 to 4.2 L/min/m2.
11
Q
What should the nurse teach the patient being evaluated for rhythm disturbances with a Holter monitor to do?
a. Remove the electrodes to shower or bathe.
b. Exercise as much as possible while his monitor is in place.
c. Keep a diary of his activities as long as he wears the monitor.
d. Attach the recorder, and call the assigned number if an episode of irregular heartbeats occurs.
A
ANS: C
The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities.
12
Q
When auscultating over the patient’s abdominal aorta, the nurse hears a humming sound. How will the nurse document this finding?
a. Bruit
b. Thrill
c. Heave
d. Arterial obstruction
A
ANS: A
A bruit is the sound created by turbulent blood flow in an artery.
13
Q
The physician orders serum troponin levels in a patient with a possible myocardial infarction. What will the nurse explain to the patient about this test?
a. It is the most specific indicator for myocardial damage available.
b. It measures the amount of myoglobin released from damaged myocardial cells.
c. It can provide evidence of myocardial damage more quickly than can enzyme tests.
d. It is diagnostic for myocardial damage only when used in combination with creatinine kinase-MB isoenzymes.
A
ANS: C
Cardiac troponins start to elevate 1 hour after myocardial injury and are specific to myocardium.
14
Q
Which of the following is a normal age-related change in the heart?
a. Increased elastin
b. Decreased collagen
c. Decreased cardiac output
d. Increased stroke volume
A
ANS: C
A normal age-related change in the heart is a decrease in cardiac output. Elastin and stroke volume are decreased, and collagen is increased.
15
Q
The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth intercostal space and midclavicular line. What is the best way to record this information?
a. “Systolic murmur heard at mitral area.”
b. “Diastolic murmur heard at aortic area.”
c. “Systolic murmur heard at Erb’s point.”
d. “Diastolic murmur heard at tricuspid area.”
A
ANS: A
The S1 sound is created by closure of the mitral and tricuspid valves and signifies the onset of ventricular systole. S2 is caused by the closure of the aortic and pulmonic valves and signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur.
16
Q
What should the nurse expect as a possible etiology in a patient who exhibits a positive Homans sign?
a. Thyrotoxicosis
b. Thrombophlebitis
c. Incompetent valves
d. Intermittent claudication
A
ANS: B
The nurse should suspect thrombophlebitis in a patient who exhibits a positive Homans sign.
17
Q
Upon auscultation, the nurse identifies an arterial bruit. What is a possible cause?
a. Cardiac dysrhythmias
b. Aneurysm
c. Pericarditis
d. Cardiac valve disorder
A
ANS: B
An arterial bruit is suggestive of wither an aneurysm or an arterial obstruction.
18
Q
The 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 does which of the following?
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. Places the patient in the left lateral position to check for the PMI
d. Uses the palm of the hand to assess extremity skin temperature
A
ANS: B
The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected; however, they are not dangerous to the patient.
19
Q
A patient with syncope is scheduled for Holter monitoring. When teaching the patient about the purpose of the procedure, the nurse explains that Holter monitoring provides information about which of the following?
a. Ventricular ejection fraction during usual daily activities
b. Cardiovascular response to high-intensity exercise
c. Changes in cardiac output when the patient is resting
d. HR and rhythm during normal patient activities
A
ANS: D
Holter monitoring is used to assess for possible changes in HR or rhythm over a 24- to 48-hour period. The patient is usually instructed to continue with usual daily activities rather than changing exercise or activity level.
20
Q
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of these actions included in the standard TEE orders will the nurse need to accomplish first?
a. Make the patient nothing by mouth (NPO) status.
b. Start a large-gauge IV line.
c. Administer O2 per mask.
d. Give lorazepam (Ativan) 1 mg IV.
A
ANS: A
The patient will need to be NPO status for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received.
21
Q
Which one of the following central venous pressure (CVP) readings would the nurse report to the physician as being abnormal?
a. 3 mm Hg
b. 6 mm Hg
c. 9 mm Hg
d. 12 mm Hg
A
ANS: D
The normal CVP reading is 2 to 9 mm Hg.
22
Q
A new patient is seen at an outpatient clinic for a routine health examination. During the patient’s initial visit, which technique would the nurse use to assess the patient’s blood pressure (BP)?
a. Have the patient sit with the arm supported at heart level, and measure the BP in each arm first.
b. Average all the BP readings obtained in both arms to establish a baseline BP for the patient.
c. Measure the first BP with the patient lying supine, and repeat the measurement in 5 minutes in the opposite arm.
d. Take additional measurements if there is a difference of more than 10 mm Hg between the first and second BP readings.
A
ANS: A
To obtain the baseline BP, the patient’s arm should be at the level of the heart. The BP is obtained in both arms; if there is a difference, the arm with the higher pressure should be used to monitor BP.
23
Q
The nurse assesses the risk factors for hypertension in a patient with high normal BP. Which risk factor would the nurse identify from the health history and advise the patient to change, in order to prevent hypertension?
a. Little or no regular exercise
b. No use of relaxation techniques
c. High dietary intake of simple sugars
d. Drinking wine with dinner once a week
A
ANS: A
The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week.
24
Q
The nurse measures the BP of a 78-year-old patient and finds it to be 168/86 mm Hg in both arms. What will the nurse include in the teaching plan for this patient?
a. Increased BP is a normal finding in older adults.
b. Prehypertension indicates the need for lifestyle changes.
c. It is important to address the increased BP.
d. A high probability of kidney and heart disease exists.
A
ANS: C
Although an increase in systolic BP (SBP) is a common finding in older adults, the recommendations for treating elevated BP are unchanged. An SBP of >140 mm Hg is a more important cardiovascular risk factor than diastolic BP (DBP) in individuals older than 50. The diagnosis of prehypertension indicates a systolic BP between 120 and 139 mm Hg and a DBP between 80 and 89 mm Hg.
25
Why should the nurse teach a patient who is taking labetalol (Normodyne) for treatment of hypertension to change position slowly?
a. The medication blocks the vasoconstrictive and sodium-retaining properties initiated by the presence of angiotensin.
b. The medication paralyzes the smooth muscle of blood vessels, and they cannot constrict in response to sympathetic stimulation.
c. The medication blocks the normal sympathetic nervous system response to position changes in vasoconstriction and increased heart rate.
d. The medication blocks the movement of calcium into the cardiac cells, and cardiac output cannot increase in response to decreased BP.
ANS: C
Labetalol decreases sympathetic nervous system activity by blocking both α- and β-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which lower BP.
26
A patient with hypertension asks the nurse why lifestyle changes are needed when the patient has no symptoms from the high BP. Which response is most likely to improve patient’s compliance with therapy?
a. “High BP damages the blood vessels, leading to risk for heart attack, stroke, and kidney failure.”
b. “High BP increases blood flow to the kidneys, leading to increased workload for the renal system.”
c. “High BP may not cause any problems for some people but does cause symptoms in many others.”
d. High BP is probably causing the damage, but the patient does not recognize that they are occurring.
ANS: A
Teaching the patient that hypertension can damage blood vessels and eventually causes severe health problems is most likely to improve patient compliance with needed lifestyle changes.
27
During assessment of a patient who has stage 2 hypertension, the nurse recognizes that it is common for the patient to experience which of the following?
a. Nosebleeds
b. No symptoms
c. Blurred vision
d. Dyspnea on exertion
ANS: B
| Hypertension is largely asymptomatic until damage to target organs has occurred.
28
The nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented to manage BP. Which diet choice indicates that the teaching has been effective?
a. The patient has a glass of low-fat milk with each meal.
b. The patient has only one cup of coffee in the morning.
c. The patient restricts intake of dietary protein.
d. The patient has tomato juice and bacon for breakfast.
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ANS: A
The DASH (Dietary Approaches to Stop Hypertension) recommendations for prevention of hypertension include increasing the intake of calcium-rich foods.
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29
The nurse is planning patient teaching for a patient who has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which of the following information is important to include when teaching the patient?
a. Increase fluid intake if dryness of the mouth is a problem.
b. Check BP daily before taking the medication.
c. Include high-potassium foods such as citrus fruits in the diet.
d. Change position slowly to help prevent dizziness and falls.
ANS: D
Angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change.
30
During assessment of a 50-year-old patient who has newly diagnosed stage 1 hypertension, the patient admits he uses a lot of salt on his foods and has not been able to lose the 13.6 kg he has gained in the last 10 years. He does not understand why he has hypertension because he is not an anxious person. What is an appropriate nursing diagnosis for the nurse to document for the patient?
a. Noncompliance related to lack of motivation
b. Disturbed self-esteem related to diagnosis of hypertension
c. Ineffective health maintenance related to lack of knowledge of disease process and management
d. Anxiety related to complexity of management regimen and lifestyle changes associated with hypertension
ANS: C
This patient’s subjective and objective assessment data indicate that lack of knowledge about hypertension will need to be addressed to allow the patient to improve the BP.
31
Laboratory testing is ordered for a patient during a clinic visit for routine assessment of hypertension. When the results of the testing are available, the nurse recognizes that target organ damage is indicated by which of the following results?
a. Blood urea nitrogen (BUN) of 5.4 mmol/L (15 mg/dL)
b. Serum uric acid of 464 μmol/L (7.8 mg/dL)
c. Serum creatinine of 230 μmol/L (2.6 mg/dL)
d. Serum potassium of 3.2 mmol/L (3.2 mEq/L)
ANS: C
BUN and creatinine are useful in determining whether renal failure is developing as a result of hypertension. The BUN level is normal. The serum creatinine is elevated and will require further investigation.
32
A 62-year-old patient is admitted to the hospital with a BP of 240/118 mm Hg. The patient has been taking clonidine hydrochloride (Catapres) and hydrochlorothiazide (HydroDIURIL) for 10 years for hypertension. What is the most appropriate question the nurse can ask at this time?
a. “Have you recently taken any antihistamine medications?”
b. “Have you been taking the clonidine and hydrochlorothiazide lately?”
c. “Did you have any recent stressful events in your life?”
d. “Did you take any acetaminophen yet today?”
ANS: B
| Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis.
33
Which of the following amounts of exercise recommended by the Canadian Hypertension Education Program (CHEP) to reduce the possibility of a person becoming hypertensive?
a. 30 minutes of light exercise daily
b. 60 minutes of moderate exercise, twice a day, three times per week
c. 30 to 60 minutes of moderate exercise, four to seven times per week
d. 30 to 45 minutes of heavy exercise, three times per week
ANS: C
CHEP recommends 30 to 60 minutes of moderate-intensity exercise four to seven times per week. Higher intensities of exercise are no more effective.
34
A 69-year-old woman is diagnosed with hypertension and placed on acebutolol (Sectral). After reviewing the patient’s history, the nurse consults with the physician about the use of this medication upon finding which of the following conditions?
a. Asthma
b. Peptic ulcer disease
c. Alcohol dependency
d. Myocardial infarction
ANS: A
Acebutolol is a β-adrenergic agent that blocks β1-adrenergic receptors. It may cause bronchospasm so you would use it with caution, especially in patients with a history of asthma.
35
A 52-year-old woman has no history of hypertension and no risk factors related to hypertension. During an annual physical examination, her blood pressure is 188/106 mm Hg. After reconfirming her BP, it is appropriate for the nurse to tell the patient which of the following?
a. She should have her BP rechecked in 2 months.
b. She is in imminent danger of a stroke and should be hospitalized immediately.
c. She needs to reduce the sodium and fat content in her diet and exercise more vigorously.
d. Her increased BP might be due to a specific disease and may require further diagnostic testing.
ANS: D
A sudden increase in BP in a patient with no previous hypertension history or risk factors indicates that the hypertension may be secondary to some other problem and requires further diagnostic testing.
36
An 86-year-old widow is a retired homemaker who lives alone and is on a fixed income. She tells the nurse the names of her medications and when she takes them. She has labelled and filled an egg carton with her medications to keep on schedule. Over time, however, it is apparent that her BP is not well controlled, and she does not always take her medication regularly. What is a possible cause of the lack of responsiveness to therapy that the nurse should explore with the patient?
a. A lack of teaching about hypertension
b. A lack of money to purchase the medication
c. A complex and inconvenient dosing schedule
d. The development of confusion and memory deficit
ANS: B
| The cost of medications is a common cause of lack of medication compliance in older patients with fixed incomes.
37
A patient with stage 1 hypertension who received a new prescription for methyldopa returns to the health clinic after 2 weeks for a follow-up visit. BP is unchanged from the previous clinic visit. What is the nurse’s first action?
a. Ask the patient about whether the medication is actually being taken.
b. Teach the patient about the reasons for an increase in the medication dose.
c. Provide information about the use of multiple drugs to treat hypertension.
d. Remind the patient that lifestyle changes are also important in BP control.
ANS: A
Methyldopa can cause adverse effects (such as impotence, decreased libido, fatigue, and depression) in some patients, leading to noncompliance. It is important to determine whether the patient has stopped taking the medication before initiating any changes in therapy, such as increasing the dose or adding a second medication.
38
The charge nurse observes a new registered nurse (RN) doing discharge teaching for a hypertensive patient who has a new prescription for enalapril (Vasotec). The charge nurse will need to intervene if the new RN tells the patient to do which of the following?
a. Increase the dietary intake of high-potassium foods.
b. Move slowly when moving from a lying to a standing position.
c. Check the BP with a home BP monitor every day.
d. Make an appointment with the dietitian for teaching about a low-sodium diet.
ANS: A
| ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect.
39
Which of the following is a correct mechanism action of aldosterone?
a. Increased sodium reabsorption
b. Decreased water reabsorption
c. Decreased blood volume
d. Increased potassium excretion
ANS: A
The mechanisms of aldosterone include an increase in sodium and water reabsorption and an increase in blood volume and cardiac output.
40
When teaching a patient about nutritional therapy related to hypertension, the nurse tells the patient to consume how many servings per day of whole grains?
a. Two to three
b. Four to five
c. Six to eight
d. Avoid intake of whole grains.
ANS: C
| Hypertensive diet indicates that patients should have a daily intake of six to eight servings of whole grains.
41
Which diuretic would the nurse anticipate that the patient with renal insufficiency would be prescribed?
a. Metolazone (Zaroxolyn)
b. Indapamide (Lozide)
c. Bumetanide (Burinex)
d. Chlorthalidone hydrochlorothiazide
ANS: C
The patient with renal insufficiency would be prescribed a loop diuretic such as bumetanide rather than a thiazide or other related diuretic.
42
A patient with hypertension has just developed an abrupt elevation in BP. Which of the following would indicate that the patient is in a hypertensive crisis?
a. Widening pulse pressure
b. Systolic above 110 mm Hg
c. Diastolic above 120 mm Hg
d. Mean arterial pressure of 82 mm Hg
ANS: C
| Hypertensive crisis is a severe and abrupt elevation in BP and is defined as a DBP above 120 to 130 mm Hg.
43
During the change-of-shift report, the nurse obtains all of this information about a hypertensive patient who received the first dose of nadolol pindolol (Visken) during the previous shift. Which of the following information will be of most concern to the nurse?
a. The patient’s heart rate has dropped from 64 to 58 beats/min.
b. The patient has developed wheezes throughout the lung fields.
c. The patient complains that the fingers and toes feel quite cold.
d. The patient’s most recent BP is 156/94 mm Hg.
ANS: B
The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect) is occurring. The nurse should immediately obtain an oxygen saturation measurement, apply supplemental oxygen, and notify the physician.
44
When developing a health teaching plan for a 65-year-old patient with all of these risk factors for coronary artery disease (CAD), which of the following will the nurse focus on?
a. A family history of heart disease
b. Increased risk associated with the patient’s ethnicity
c. A high incidence of cardiovascular disease in older people
d. A low activity level reported by the patient
ANS: D
Because family history, ethnicity, and age are nonmodifiable risk factors, the nurse should focus on the patient’s activity level. An increase in activity will help reduce the patient’s risk for developing CAD.
45
To assist the patient with CAD to make the appropriate dietary changes, which of these nursing interventions will be most effective?
a. Help the patient modify favourite high-fat recipes by using monounsaturated oils when possible.
b. Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet.
c. Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary.
d. Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes.
ANS: A
Lifestyle changes are more likely to be successful when consideration is given to patient’s preferences. The highest percentage of calories from fat should come from monounsaturated fats.
46
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)?
a. The pain worsens when the patient raises the arms.
b. The pain increases with deep breathing.
c. The pain is relieved after the patient takes nitroglycerin.
d. The pain has persisted longer than 30 minutes.
ANS: D
| Chest pain that lasts for 20 minutes or more is characteristic of AMI.
47
A 45-year-old man is admitted to the ED after developing severe chest pain while raking leaves. On admission, he has midchest dullness and a normal electrocardiogram (ECG). The physician schedules the patient for cardiac catheterization with coronary angiography and possible percutaneous coronary intervention (PCI). The nurse prepares the patient for the procedure by explaining that, in his case, it is used for which of the following purposes?
a. To determine whether the walls or chambers of the patient’s heart have any structural defects
b. To determine whether any obstructions are present in his coronary arteries and to test for an allergy to thrombolytic agents
c. To measure the amount of blood being pumped from his heart with each contraction to determine whether the heart is damaged
d. To visualize any blockages in the coronary arteries and, if necessary, to dilate an obstructed artery with the use of a small balloon
ANS: D
In this case, PCI is used for visualization of the coronary arteries, and possible balloon dilation is scheduled for this patient.
48
During assessment of a patient with chest pain, how will the nurse recognize the chest pain associated with stable angina?
a. It is severe, persistent, and unrelieved by rest.
b. Cold, clammy skin accompanied by a feeling of doom.
c. It is aggravated by inspiration, coughing, and movement of the upper body.
d. It is accompanied by a residual soreness in the chest, which lasts for several days.
ANS: B
| Stable angina chest pain is usually abrupt, and the patient has a feeling of impending doom.
49
While observing the ECG monitor of a patient admitted to the ED with chest pain, the nurse suspects that the patient is having a myocardial infarction (MI) rather than angina on finding which of the following data?
a. Sinus tachycardia
b. Depressed R wave
c. Pathological Q wave
d. Occasional premature ventricular contractions
ANS: C
Patients with ST-segment–elevation myocardial infarction (STEMI) tend to have a more extensive MI associated with prolonged and complete coronary occlusion and the development of a pathological Q wave on the ECG. Patients with unstable angina or non– ST-segment–elevation myocardial infarction (NSTEMI) usually have transient thrombosis or incomplete coronary occlusion and usually do not develop pathological Q waves.
50
Which of the following determinants of health is true in relation to CAD in Canada?
a. Native-born Canadians have better cardiovascular health than immigrants to Canada.
b. Immigrants from South Asia have a very high risk for cardiovascular disease.
c. Asian Indians experience lower rates of cardiovascular disease, regardless of where they live.
d. Chinese immigrants have a very low rate of cardiovascular disease.
ANS: D
Immigrants from China have a particularly low rate of cardiovascular disease. Immigrants to Canada have better cardiovascular health than do native-born Canadians. Immigrants from South Asia have a particularly high risk for cardiovascular disease. Regardless of where they live, Asian Indians appear to suffer high rates of cardiovascular disease.
51
In developing a teaching plan for a patient who has stable angina and is started on sublingual nitroglycerin, which one of the following would the nurse identify as an expected patient outcome?
a. States nitroglycerin is to be taken only if chest pain develops
b. Lists the side effects of nitroglycerin as gastric upset and dry mouth
c. Identifies the need to seek medical attention if chest pain persists 5 minutes after taking nitroglycerin
d. Identifies the need for lifelong use of nitroglycerin to prevent the development of an MI
ANS: C
The emergency medical services system should be activated when chest pain or other symptoms are not completely relieved 5 minutes after taking nitroglycerin.
52
While teaching a patient and his wife about the dietary modifications that should be made to reduce the risk of CAD, what should the nurse explain?
a. Margarine can be used in any amount, but butter should be avoided.
b. Fish is preferable to red meats as sources of protein.
c. All vegetable fats are unsaturated and are preferable to meat and dairy fats.
d. Polyunsaturated and monounsaturated fats should be restricted to 50% of the total daily calories.
ANS: B
Fish and skinless chicken are preferable as sources of protein, as red meat is high in animal (saturated) fat, and patients are advised to reduce their saturated fat intake.
53
The nurse determines that outcomes for teaching regarding precipitating factors of angina have been met when the patient states which of the following?
a. “I will stop my sexual activities.”
b. “I will rest for 1 to 2 hours after a heavy meal.”
c. “I will take my medication before doing my daily walk.”
d. “I will limit my coffee intake, but I may substitute regular cola products.”
ANS: B
Adequate rest should be planned for 1 to 2 hours after eating because blood is shunted to the gastrointestinal tract to aid digestion and absorption.
54
After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by the patient indicates that the teaching has been effective?
a. “Atenolol will increase the strength of my heart muscle.”
b. “I can expect to feel short of breath when taking atenolol.”
c. “Atenolol will improve the blood flow to my coronary arteries.”
d. “It is important not to suddenly stop taking the atenolol.”
ANS: D
Patients who have been taking β-blockers can develop intense and frequent angina if the medication is suddenly discontinued.
55
In developing a teaching plan for the patient with angina, the nurse recognizes that teaching about the first line of drug therapy for angina will include instructions about using which of the following medications?
a. One aspirin a day
b. Transdermal nitrates
c. Lovastatin (Mevacor)
d. Metoprolol (Lopressor)
ANS: A
| Daily aspirin is recommended in the absence of contraindications.
56
Which of the following is the earliest lesion of atherosclerosis and is characterized by lipid-filled smooth muscle cells?
a. Fatty streak
b. Fibrous plaque
c. C-reactive lesion
d. Complication lesion
ANS: A
| Fatty streaks, the earliest lesions of atherosclerosis, are characterized by lipid-filled smooth muscle cells.
57
Nadolol (Corgard) is prescribed for a patient with CAD. In evaluating the effectiveness of the drug, the nurse would monitor for which of the following?
a. Improvement in the quality of the peripheral pulses
b. Ability to do daily activities without chest discomfort
c. Decreased blood pressure and apical pulse rate
d. Fewer complaints of having cold hands and feet
ANS: B
Because the medication is ordered to improve the patient’s angina, effectiveness is indicated if the patient’s angina is stable.
58
A patient admitted to the critical care unit (CCU) with an MI has a physician’s orders for continuous amiodarone (Cordarone) infusion, intravenous (IV) nitroglycerin, and morphine sulphate 2 mg IV every 5 minutes until relief of pain occurs, in addition to the standard CCU protocol. The patient is having frequent, multifocal premature ventricular contractions, and he tells the nurse that the pain is worse than he has ever had and asks if he is going to die. On admission to the CCU, the nurse identifies which of the following nursing diagnoses as a priority?
a. Acute pain related to myocardial ischemia
b. Anxiety related to perceived threat of death
c. Decreased cardiac output related to cardiogenic shock
d. Activity intolerance related to decreased cardiac output
ANS: A
All the nursing diagnoses may be appropriate for this patient, but the data indicate that the priority diagnosis is pain, a physiological stressor. The patient’s anxiety will also be reduced if the pain is resolved.
59
A diagnosis of acute coronary syndrome (ACS) is the admission diagnosis for a patient transferred to the CCU. The nurse knows that this diagnosis indicates that the patient has experienced which of the following?
a. Unstable angina (UA) or an MI
b. Resuscitation following sudden cardiac death
c. Onset of any severe cardiac-related chest pain
d. MI accompanied by ST-segment elevation
ANS: A
| ACS develops and encompasses the spectrum of UA, NSTEMI, and STEMI.
60
While caring for a patient with an AMI, the nurse monitors the patient closely, knowing that which of the following conditions is the most common complication of MI?
a. Pericarditis
b. Dysrhythmias
c. Cardiogenic shock
d. Congestive heart failure
ANS: B
| Dysrhythmias are the most common complication of MI.
61
The nurse administers IV nitroglycerin to a patient with an MI. In evaluating the effect of this intervention, the nurse recognizes that which of the following is an expected outcome of the administration of the medication?
a. Relief of pain
b. Decreased heart rate
c. Increased cardiac output
d. Control of cardiac dysrhythmias
ANS: A
The goal of IV nitroglycerin administration in AMI is relief of chest pain by improving the balance between myocardial oxygen supply and demand.
62
The MB isoenzyme of creatine kinase (CK-MB) level is markedly elevated in a patient with chest pain 12 hours after admission. Of what would the nurse interpret this finding as being evidence?
a. Lactic acidosis
b. A need for thrombolytic therapy
c. Deterioration of cardiac function
d. Cellular necrosis of myocardial tissue
ANS: D
The CK-MB levels increase as the necrotic myocardial cells release CK-MB enzymes into the circulation after perfusion has been restored to the area.
63
The physician has ordered determination of CK-MB and troponin levels for a patient who has experienced chest pain and aching for the last 4 days. What does the nurse expect on reading this order?
a. Myoglobin levels will also have to be determined to confirm myocardial damage.
b. CK-MB enzyme levels will be the most reliable indicator of any myocardial necrosis that has occurred.
c. Any serum cardiac marker will be inconclusive in determining myocardial injury that is several days old.
d. The presence of myocardial damage occurring several days earlier can be validated best by the troponin level determination.
ANS: D
The heart has two troponin subtypes: cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI). These markers are highly specific indicators of MI and have greater sensitivity and specificity for myocardial injury than CK-MB (Pagana & Pagana, 2006). Troponin rises as quickly as CK. It is usually used for diagnostic purposes in conjunction with total CK and the MB fraction. Serum levels of cTnI and cTnT increase 3 to 12 hours after the onset of MI, peak at 24 to 48 hours, and return to baseline over 5 to 14 days.
64
Fibrinolytic therapy is prescribed for a 64-year-old patient with an STEMI. During the administration of the fibrinolytic agent, the nurse recognizes that the therapy should be stopped when the patient experiences which of the following signs?
a. Bleeding from the gums
b. Surface bleeding from the IV site
c. A sudden decrease in the level of consciousness
d. Premature ventricular contractions and ventricular tachycardia
ANS: C
The change in the level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of fibrinolytic therapy.
65
Which of the following signs would the patient experience when the nurse evaluates that fibrinolytic therapy has not been successful in restoring perfusion to the myocardium?
a. Continuing chest pain
b. Dyspnea and tachycardia
c. A marked, rapid rise in the CK enzyme
d. An increase in premature ventricular contractions
ANS: A
| If the patient’s chest pain continues, it is an indication that perfusion has not been restored to the myocardium.
66
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, what would the nurse expect to hear?
a. Distant heart sounds
b. S3 or S4 heart sounds
c. A pericardial friction rub
d. A loud holosystolic apical murmur
ANS: C
The patient’s symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient’s symptoms.
67
For which of the following patient conditions is the use of garlic as a complementary therapy to help lower blood pressure contraindicated?
a. Pre-existing hypertension
b. Diabetes
c. Obesity
d. Osteoarthritis
ANS: B
Garlic is a relatively safe herb but is contradicted in people with bleeding disorders, GI infections, diabetes, and inflammation.
68
Which of the following is a mnemonic to assist the nurse in obtaining thorough information from a patient who has chest pain?
a. ABCDEF
b. PAIN
c. PQRST
d. AQSP
ANS: C
PQRST can be used as a mnemonic to assist in obtaining information for the patient who has chest pain as follows: P, precipitating events; Q, quality of pain; R, radiation of pain; S, severity of pain; and T, timing.
69
A patient has had an elevated temperature of 38.2°C for 3 days since experiencing an MI. What does the nurse understand that this fever indicates?
a. A normal response to the necrotic tissue of infarction
b. A need for concern only if a leukocytosis is also present
c. Beginning congestive heart failure from increased myocardial oxygen demand
d. Developing pericarditis as a complication of myocardial necrosis
ANS: A
Fever and elevated white blood cell count are normal occurrences after MI as a result of inflammation that occurs after tissue necrosis.
70
When caring for a patient who has survived a sudden cardiac death event and has no evidence of an AMI, what will the nurse anticipate teaching the patient?
a. That sudden cardiac death events rarely recur
b. The purpose of outpatient Holter monitoring
c. How to self-administer low–molecular weight heparin
d. The need to limit activities after discharge to prevent future events
ANS: B
Holter monitoring is used to determine whether the patient is experiencing dysrhythmias such as ventricular tachycardia during normal daily activities.
71
During the initial stages of hospitalization for an MI, the patient has been in denial, stating “I just had a little chest pain.” What is the most appropriate intervention for the nurse to plan for the patient at this time?
a. Have the patient’s family encourage him to talk about his plans for the future.
b. Allow the patient to use denial as a coping mechanism until he asks questions about his condition.
c. Implement reality orientation by reminding the patient several times a day that he has had major cardiac damage.
d. Begin teaching the patient about the anatomy and physiology of the heart so that he can understand what has happened to him.
ANS: B
| The patient is experiencing progression through the normal stages of loss and grief that often occur after an MI.
72
The nurse evaluates the outcomes of preoperative teaching with a patient scheduled for a coronary artery bypass graft using the internal mammary artery. Which of the following statements by the patient helps the nurse identify that additional teaching is needed?
a. “I will need to take an aspirin a day after the surgery to keep the graft open.”
b. “I will have incisions in my leg where they removed the vein.”
c. “They will stop my heart and circulate my blood with a machine during the surgery.”
d. “They will cut between my ribs and use a scope to attach a different artery to the artery that is blocked in my heart.”
ANS: B
| When the internal mammary artery is used, it will not be necessary to remove a saphenous vein from the leg.
73
Three weeks after his hospitalization for an AMI, a patient returns to the cardiac centre for follow-up. When the nurse asks about his sleep patterns, the patient tells the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned home. He states, “I guess we will never have sex again after this.” What is the best response to the patient?
a. “Sexual intercourse will be too strenuous on your heart, but closeness and intimacy can be maintained with holding and cuddling.”
b. “You should discuss your questions about your sexual activity with your doctor because the activity it requires is a medical concern.”
c. “Sexual activity can be resumed whenever you and your wife feel like it. Most sexual response is emotional rather than physical.”
d. “Sexual activity can be gradually resumed like other forms of activity. A good comparison of energy expenditure is climbing two flights of stairs.”
ANS: D
All activity has to be gradually resumed. A good guide for patients is to tell them that sexual activity places about as much physical stress on the cardiovascular system as climbing two flights of stairs.
74
In preparing a patient for discharge from the hospital following an MI, which of the following statements by the patient indicates to the nurse that further instruction is needed?
a. “Exercise will increase the efficiency of my heart.”
b. “I can control several risk factors of CAD just by exercising.”
c. “My heart will be as good as new when I finish a cardiac rehabilitation program.”
d. “I should do more exercises that move my joints than exercises that require static force.”
ANS: C
| It is important for the patient to understand that CAD is a chronic disease that can be managed but cannot be cured.
75
Which of the following is the mechanism of action of aspirin that is commonly prescribed for patients that have had acute coronary syndrome?
a. Inhibits platelet aggregation
b. Promotes coronary artery vasodilation
c. Promotes peripheral vasodilation
d. Inhibits cyclooxygenase
ANS: D
Aspirin is used as an antiplatelet agent in the treatment of acute coronary syndrome; it inhibits cyclooxygenase which produces thromboxane A2, a potent platelet activator.
76
During early assessment of the patient with an MI, the nurse is aware that which of the following diagnostic tests is the most important to determine the extent and treatment of an MI?
a. Serial ECGs
b. A chest X-ray
c. Treadmill exercising
d. Serum cardiac markers
ANS: A
When the initial ECG is nondiagnostic, serial ECGs are done every 2 to 4 hours to determine the extent and treatment of an MI.
77
A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports all the following symptoms to the nurse. Which one is most important to communicate to the physician?
a. Skin flushing after taking the medications
b. Dizziness when changing positions quickly
c. Nausea when taking the drugs before eating
d. Generalized muscle aches and pains
ANS: D
Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute kidney injury and death in some patients who have taken the statin medications. These symptoms indicate that the rosuvastatin may have to be discontinued.
78
A patient who has chest pain is admitted to the ED, and the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first?
a. Chest X-ray
b. Troponin level
c. Computed tomography scan
d. ECG
ANS: D
The priority for the patient is to determine whether an AMI is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion.
79
For a patient who was admitted the previous day to the CCU with an AMI, the nurse will anticipate teaching the patient about which one of the following?
a. The pathophysiology of CAD
b. When patient cardiac rehabilitation will begin
c. Home-discharge drugs such as aspirin and b-blockers
d. Typical emotional responses to MI
ANS: B
At this time, the patient’s anxiety level or denial will prevent good understanding of complex information such as CAD pathophysiology.
80
Which of the following is an absolute contraindication for the use of fibrinolytic therapy?
a. Diabetes
b. Pregnancy
c. Intercranial neoplasm
d. Laser eye surgery
ANS: C
An absolute contraindication for the use of fibrinolytic therapy is intercranial neoplasm. Diabetes is not a contraindication. Pregnancy and laser eye surgery are relative contraindications but not absolute ones.
81
A patient who is being admitted to the ED with severe chest pain gives the nurse the following list of medications taken at home. Which medication has the most immediate implications for the patient’s care?
a. Captopril (Capoten)
b. Furosemide (Lasix)
c. Sildenafil (Viagra)
d. Diazepam (Valium)
ANS: C
The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of sudden death caused by vasodilation.
82
The nurse has just received a change-of-shift report about the following four patients. Which patient should the nurse assess first?
a. A 38-year-old patient who has pericarditis and is complaining of sharp, stabbing chest pain
b. A 45-year-old patient who had an MI 4 days ago and is anxious about the planned discharge
c. A 51-year-old patient who has just returned to the unit after a coronary arteriogram and PCI
d. A 60-year-old patient who is due for a scheduled dose of atenolol 25 mg orally
ANS: C
After PCI, the patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient immediately. The other patients also should be assessed as quickly as possible, but assessment of this patient has the highest priority.
83
A patient with a history of chronic congestive heart failure is hospitalized with severe dyspnea and a dry, hacking cough. She has pitting edema in both ankles, and her vital signs are blood pressure (BP) 170/100 mm Hg, pulse 92 beats/min, and respiration 28 breaths/min. What is the most important assessment for the nurse to conduct next?
a. Auscultate the lung sounds.
b. Assess the orientation.
c. Check the capillary refill.
d. Palpate the abdomen.
ANS: A
When caring for a patient with severe dyspnea, the nurse should use the ABCs (airway, breathing, circulation) to guide initial care. This patient’s severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac or respiratory arrest. The other assessments will provide useful data about the patient’s volume status and should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority.
84
A patient with chronic heart failure tells the nurse at the clinic that he has gained 2.26 kg in the last 3 days, even though he has continued to follow a low-sodium diet. What is the priority nursing action?
a. Ask the patient to recall the dietary intake for the last 3 days because the patient’s diet contains hidden sources of sodium.
b. Instruct the patient in a low-calorie, low-fat diet because the weight gain has likely been caused by excessive intake of inappropriate foods.
c. Assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring.
d. Educate the patient about the use of diuretic therapy because it is likely that the patient will need medications to reduce the hypervolemia.
ANS: C
The 2.26-kg weight gain over 3 days indicates that the patient’s chronic heart failure may be worsening. It is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles.
85
During assessment of a 72-year-old man with swelling in his ankles, the nurse finds jugular venous distension with the head of the bed elevated 45 degrees. What does the nurse know this finding indicates?
a. Decreased fluid volume
b. Elevated right atrial pressure
c. Incompetent jugular vein valves
d. Atherosclerosis of the jugular veins
ANS: B
Right-sided heart failure causes backward blood flow to the right atrium and venous circulation. Venous congestion in the systemic circulation results in peripheral edema, hepatomegaly, splenomegaly, vascular congestion of the gastrointestinal tract, and jugular venous distension.
86
The nurse monitors a patient receiving intravenous (IV) furosemide (Lasix) and enalapril (Vasotec) 5 mg orally twice daily for an acute exacerbation of chronic heart failure. Which of the following findings indicates to the nurse that the treatment is effective?
a. A weight loss of 0.9 kg
b. An increase in urinary output
c. A decrease in systolic BP
d. Fewer crackles on lung auscultation
ANS: D
Because the patient’s major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in crackles
87
When the nurse is developing a teaching plan to prevent the development of heart failure in a patient with stage 1 hypertension, what information is most likely to improve compliance with antihypertensive therapy?
a. Hypertensive crisis may lead to development of acute heart failure in some patients.
b. Hypertension eventually will lead to heart failure by overworking the heart muscle.
c. High BP increases the risk for rheumatic heart disease.
d. High systemic pressure precipitates papillary muscle rupture.
ANS: B
Hypertension is a primary cause of heart failure because the increase in ventricular afterload leads to ventricular hypertrophy and dilation.
88
A patient with acute heart failure has severe dyspnea and is extremely anxious. The nurse anticipates that increased cardiac output and decreased anxiety may be promoted by the IV administration of which of the following medications?
a. Morphine
b. Diazepam (Valium)
c. Dopamine (Intropin)
d. Nitroglycerin (Tridil)
ANS: A
Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea.
89
IV nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the initial administration of the drug, the nurse should monitor the patient for which of the following?
a. Bradycardia
b. Hypotension
c. Cyanide toxicity
d. Ventricular dysrhythmias
ANS: B
| Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension.
90
A patient admitted to the hospital with an exacerbation of her chronic heart failure tells the nurse she was fine when she went to bed but woke up feeling as if she were suffocating. What is the best way for the nurse to document this assessment information?
a. Pulsus alternans
b. Paroxysmal nocturnal dyspnea
c. Two-pillow orthopnea
d. Acute bilateral pleural effusion
ANS: B
Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation.
91
Which IV medication will the nurse expect to administer to a patient who has ADHF, to increase stroke volume?
a. Milrinone (Primacor)
b. Nesiritide (Natrecor)
c. Dobutamine (Dobutrex)
d. Nitroprusside (Nipride)
ANS: C
| Dobutamine is administered IV to increase stroke volume.
92
When working in the heart failure clinic, the nurse knows that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient does which of the following?
a. Says that the nitroglycerin patch will be used for any chest pain that develops
b. Calls when the weight increases from 56 to 59 kg in 2 days
c. Tells the home care nurse that furosemide is taken daily at bedtime
d. Makes an appointment to see the doctor at least once yearly
ANS: B
Teaching for a patient with heart failure includes information about the need to weigh daily and notify the physician about an increase of 2 kg in 2 days.
93
To promote more efficient ventricular emptying by decreasing preload in the patient with chronic heart failure, the nurse should implement which of the following actions?
a. Administer oxygen per mask.
b. Encourage active leg exercises to increase venous return.
c. Administer sedatives to promote rest and decrease myocardial oxygen demand.
d. Position the patient in a high-Fowler’s position with the feet horizontal in the bed.
ANS: D
The high-Fowler’s position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. IV nitroglycerin is a vasodilator used in the treatment of ADHF. It reduces circulating volume by decreasing preload and increases coronary artery circulation by dilating the coronary arteries.
94
When teaching the patient with congestive heart failure about a 2-g sodium diet, the nurse explains that which of the following foods must be restricted?
a. Eggs
b. Canned fruit
c. Frozen vegetables
d. Milk and milk products
ANS: D
Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited for patients on a diet that limits sodium to 2 g daily. Other milk products, such as processed cheeses, have very high levels of sodium and are not appropriate for a 2-g sodium diet.
95
The nurse plans discharge teaching for a patient with chronic heart failure who is to be maintained on digoxin (Lanoxin), a diuretic, and a potassium supplement. What would appropriate instructions for the patient include?
a. Avoid dietary sources of potassium because too much can cause digitalis toxicity.
b. Take the diuretic before bedtime to prevent drowsiness during the day.
c. Notify the physician immediately if nausea or difficulty breathing occurs.
d. Take the pulse rate before taking all medications.
ANS: C
Difficulty breathing is an indication of ADHF and suggests that the medications are not achieving the desired effect. Nausea is an indication of digoxin toxicity and should be reported so that the health care provider can assess the patient for toxicity and adjust the digoxin dose, if necessary.
96
The nurse identifies the collaborative problem of “potential complication: pulmonary edema for a patient in chronic heart failure.” Which assessment will the nurse be most concerned about?
a. Apical pulse 106 beats/min
b. Weight gain of 1 kg over 24 hours
c. Oxygen saturation of 88% on room air
d. Decreased hourly urinary output
ANS: C
A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient.
97
When the nurse is admitting an 80-year-old woman with chronic heart failure to the medical unit, the patient says she lives alone and that she thinks she confuses her “water pill” with her “heart pill.” The nurse makes a note that which of the following discharge plans for this patient should be included?
a. A referral for a home care nurse
b. Placement in a skilled nursing care facility
c. Transfer to a special unit for individuals with dementia
d. Arrangements for a family member to be with the patient around the clock
ANS: A
The data about the patient suggest that assistance is needed in developing a system for taking medications correctly at home. A home health care nurse will assess the patient’s home situation and help the patient develop a method for taking the two medications as directed.
98
After successful digitalization, a patient is to begin oral maintenance of digoxin and furosemide for control of chronic heart failure. To prevent digitalis toxicity, what does the nurse understand is the most important parameter to monitor in the patient?
a. Body weight
b. Liver function
c. Blood pressure
d. Serum potassium
ANS: D
Hypokalemia potentiates the actions of digoxin and increases the risk for digoxin toxicity, which can cause life-threatening dysrhythmias.
99
Following an acute myocardial infarction, a 67-year-old man develops heart failure. What does the nurse anticipate will be the first-line therapy for the patient?
a. Digitalis preparation, such as digoxin
b. Diuretic, such as hydrochlorothiazide (HydroDIURIL)
c. β-Adrenergic agonist, such as dobutamine
d. Angiotensin-converting enzyme (ACE) inhibitor, such as captopril (Capoten)
ANS: D
ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure.
100
Which of the following is a common cause of chronic heart failure?
a. Anemia
b. Dysrhythmias
c. Myocarditis
d. Hypertensive crisis
ANS: A
Anemia is a common cause of chronic heart failure. Dysrhythmias, myocarditis, and hypertensive crisis are all common causes of acute heart failure.
101
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. Which assessment finding causes the nurse the most concern?
a. The patient has a BP of 88/42 mm Hg.
b. The patient has an apical pulse rate of 56 beats/min.
c. The patient complains of feeling tired.
d. The patient has 2+ pedal edema.
ANS: A
The patient’s BP indicates that the dose of carvedilol may have to be decreased because the mean arterial pressure is only 57.
102
Which of the following determinants of health is true in relation to heart failure?
a. Men compose more new cases of heart failure than women.
b. Women tend to be diagnosed with heart failure at an older age as compared to men.
c. Men are more likely to be diabetic as compared to women.
d. Women are less likely to have high BP than men.
ANS: B
Women tend to be diagnosed with heart failure at an older age than men; women are more likely to be diabetic and to have high BP.
103
What is the most common form of initial heart failure?
a. Left-sided
b. Right-sided
c. Biventricular
d. All types occur equally; there is no one common form of heart failure.
ANS: A
| Left-sided heart failure is the most common form of initial failure.
104
Which of the following symptoms would the nurse expect to observe in a patient with left-sided heart failure?
a. Nausea
b. Dyspnea
c. Anorexia
d. Dependent edema
ANS: B
Dyspnea is a symptom of left-sided heart failure. Nausea, anorexia and dependent edema are all symptoms of right-sided heart failure.
105
Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid nursing intervention?
a. The patient has been vomiting several times a day for the last 4 days.
b. The patient is lethargic and difficult to arouse.
c. The patient’s chart indicates a recent resection of the small intestine.
d. The patient has taken only sips of water.
ANS: B
A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk.
106
What is the location of the vomiting centre that coordinates the multiple components involved in vomiting?
a. Chemoreceptor zone
b. Brainstem
c. Vestibular area
d. Visceral receptors from afferent fibres in the gastrointestinal (GI) tract
ANS: B
| The vomiting centre in the brainstem coordinates the multiple components involved in vomiting.
107
The nurse identifies the nursing diagnosis of deficient fluid volume for a patient with prolonged vomiting. Which of the following nursing assessments is most helpful in determining the source of the vomiting?
a. Ask the times when the vomiting occurs.
b. Determine the amount and character of the vomitus.
c. Measure the intake and output, and daily weight patterns.
d. Assess the serum sodium, potassium, and chloride levels.
ANS: A
When assessing vomiting, it is important for the nurse to assess when the vomiting occurs to help in understanding the cause.
108
A patient who has been on nothing by mouth (NPO) status during treatment for nausea and vomiting related to gastric irritation is to start oral intake of clear liquids. To promote tolerance to oral fluids, what should the nurse first offer the patient?
a. Orange juice
b. Hot chicken broth
c. A dish of lemon gelatin
d. Coffee with cream and sugar
ANS: C
Clear liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.
109
When a patient with persistent nausea and severe vomiting is admitted to the hospital for control of the symptoms, what is the first order that the nurse should act on?
a. Provide oral care with moistened swabs.
b. Infuse normal saline at 250 mL/hour.
c. Insert a 16-gauge nasogastric (NG) tube.
d. Administer intravenous (IV) ondansetron (Zofran).
ANS: B
Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated.
110
A patient who is on NPO status and has been receiving parenteral nutrition for 2 weeks develops bilateral pain in the area of the ears. The nurse recognizes that the patient is at risk for development of which of the following conditions?
a. Parotitis
b. Stomatitis
c. Oral candidiasis
d. Vincent’s infection (trench mouth)
ANS: A
Clinical manifestations of parotitis include pain and swelling in the area of the gland and ear, absence of salivation, purulent exudate from the gland, erythema, and ulcer.
111
The nurse teaches a patient who is trying to stop the use of smokeless tobacco to examine the mouth routinely for the danger signs of oral cancer, especially for the presence of which of the following signs?
a. Acutely sore ulcers
b. A red, velvety patch
c. White, curdlike plaques
d. Reddened and swollen tongue
ANS: B
A red, velvety patch suggests erythroplasia, which has a high incidence (greater than 50%) of progression to squamous cell carcinoma.
112
A 62-year-old man with weight loss, difficulty chewing, and malaise has been diagnosed with squamous cell carcinoma of the oral cavity. Which of the following information obtained from the patient during the nursing history is the most significant risk factor for oral cancer?
a. Use of tobacco
b. Neglected oral hygiene
c. Chronic overexposure to the sun
d. Recurrent herpes simplex infections
ANS: A
Tobacco use greatly increases the risk for oral cancer. A history of acute infections such as strep throat is not a risk factor for oral cancer, although chronic irritation of the oral mucosa does increase risk.
113
A patient with oral squamous cell carcinoma is transferred to the postoperative surgical unit after a hemiglossectomy and radical neck procedure. When planning care, the nurse will anticipate the need to do which of the following?
a. Insert a long-term central venous catheter for parenteral nutrition.
b. Use an alphabet board to assist the patient with communication.
c. Administer chemotherapy starting the first postoperative day.
d. Reinforce pressure dressings at the surgical incision.
ANS: B
The patient will have a tracheostomy after having a radical neck procedure, and the nurse should plan ways to allow the patient to communicate.
114
A patient with chronic gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. During assessment of the patient’s current management of the problem, the nurse determines that further teaching is needed when the patient makes which following statement?
a. “I use antacids between meals and at bedtime.”
b. “I quit smoking several years ago, but I still chew a lot of gum.”
c. “I’ve learned to sleep with the head of the bed elevated on 10-cm blocks.”
d. “I eat small meals throughout the day and have a bedtime snack.”
ANS: D
| GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime.
115
When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient’s wife that the patient has a history of GERD. About which of the following will the nurse complete frequent assessments?
a. Bowel sounds
b. Breath sounds
c. Apical pulse
d. Abdominal girth
ANS: B
Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia, so the nurse should frequently assess breath sounds.
116
A patient with recurring heartburn tells the nurse that he has used over-the-counter antacids and famotidine (Pepcid), but the physician has now prescribed esomeprazole (Nexium). In teaching the patient about this medication, what should the nurse explain about this drug?
a. It reduces the reflux of gastric acid into the esophagus by increasing the rate of gastric emptying.
b. It coats the stomach and protects the stomach lining and esophagus from the effects of increased gastric acid.
c. It is used to treat GERD by decreasing stomach acid production.
d. It provides a quick, but short-lived, relief of symptoms and is an inexpensive means of treating gastroesophageal reflux.
ANS: C
| The proton pump inhibitors decrease the rate of gastric acid secretion; therefore, production is decreased.
117
When teaching a patient with GERD about recommended dietary modifications, the nurse explains that which of the following foods decreases lower esophageal sphincter (LES) pressure and should be avoided?
a. Acidic and pickled foods
b. Coffee, tea, and chocolate
c. Milk and other dairy products
d. Spicy and highly seasoned foods
ANS: B
Foods that decrease LES pressure such as chocolate, peppermint, coffee, and tea should be avoided, because they predispose to reflux.
118
A patient returns to the surgical unit following an abdominal Nissen fundoplication for treatment of GERD. Four hours postoperatively, which one of the following is it most important for the nurse to address?
a. The patient has dyspnea and absent breath sounds throughout the left lung.
b. The patient complains of level 6 (of a 0 to 10 scale) abdominal pain.
c. The patient has decreased bowel sounds in all four quadrants.
d. The patient is experiencing intermittent waves of nausea.
ANS: A
| Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment.
119
A patient who has recently been experiencing frequent heartburn is seen in the clinic. The nurse will anticipate teaching the patient about which of the following?
a. Endoscopy procedures
b. Barium swallow
c. Radionuclide tests
d. Proton pump inhibitors
ANS: D
Because diagnostic testing for heartburn that is probably caused by GERD is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD.
120
A patient tells the nurse that when he feels nauseous, he takes ginger. The nurse should instruct the patient that he should not take ginger if he is also taking which one of the following medications?
a. Digoxin
b. Penicillin
c. Tetracycline
d. Protein pump inhibitor
ANS: A
| He should not be taking ginger if he is also taking digoxin or hypoglycemic agents, or is on anticoagulant therapy.
121
Which information will the nurse include when teaching a patient with newly diagnosed GERD?
a. “Peppermint tea may be helpful in reducing your symptoms.”
b. “You will need to keep the head of your bed elevated on blocks.”
c. “You should avoid eating between meals to reduce acid secretion.”
d. “Vigorous physical activities may increase the incidence of reflux.”
ANS: B
| Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping.
122
A patient undergoes an esophagectomy with a synthetic graft replacement for treatment of esophageal cancer. Following his return to the surgical unit, why should the nurse place the patient in a semi-Fowler’s position?
a. To facilitate respiratory function
b. To prevent reflux of gastric secretions
c. To promote drainage from the NG tube
d. To promote movement of fluids through the GI tract
ANS: B
| Postoperatively, the patient is to be in a semi-Fowler’s position to prevent reflux of gastric secretions.
123
Which of the following will the nurse plan to teach the patient with newly diagnosed achalasia?
a. Drinking fluids with meals should be avoided.
b. Lying down and resting after meals is recommended.
c. A liquid or blenderized diet will be necessary.
d. Endoscopic procedures may be used for treatment.
ANS: D
| Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia.
124
A 62-year-old patient develops an acute gastritis caused by the nonsteroidal anti-inflammatory drug (NSAID) she uses to treat her arthritis. In teaching the patient about the effects of these drugs on the stomach’s mucosal barrier, what should the nurse explain?
a. “NSAIDs stimulate histamine receptors, which increase the release of hydrochloric acid.”
b. “NSAIDs inhibit the synthesis of prostaglandins that normally decrease acid secretion in the stomach.”
c. “NSAIDs stimulate the parietal cells of the stomach to release pepsin, which is capable of digesting stomach tissue.”
d. “The inflammatory response stimulated by prostaglandin release in the stomach is increased with the use of NSAIDs.”
ANS: B
| NSAIDs are known to inhibit the synthesis of prostaglandins that are protective to the gastric mucosa.
125
Cobalamin injections have been prescribed for a patient with chronic atrophic gastritis. The nurse determines that teaching regarding the injections has been effective when the patient makes which following statement?
a. “These injections will decrease my risk of stomach cancer.”
b. “These injections will increase the hydrochloric acid in my stomach.”
c. “The cobalamin injections need to be taken until my inflamed stomach heals.”
d. “I must take these injections to prevent me from becoming anemic.”
ANS: D
| Cobalamin supplementation prevents the development of pernicious anemia.
126
A patient with chronic gastritis associated with the presence of Helicobacter pylori is treated with triple-drug therapy. Which of the following medications should the nurse explain to the patient are commonly included in this regimen?
a. Tetracycline, bismuth subsalicylate (Pepto-Bismol), and amoxicillin
b. Tetracycline, metronidazole (Flagyl), and bismuth subsalicylate (Pepto-Bismol)
c. Amoxicillin, clarithromycin (Biaxin), and omeprazole (Losec)
d. Metronidazole (Flagyl), clarithromycin (Biaxin), and omeprazole (Losec)
ANS: C
The drugs used in triple-drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin.
127
Which one of the following drug classifications increases lower esophageal sphincter pressure and is used in the treatment of GERD?
a. Prokinetic
b. Antacids
c. Cholinergic
d. H2-receptor blockers
ANS: C
| The mechanism of action of cholinergic drugs is to increase lower esophageal sphincter pressure.
128
A patient is hospitalized with vomiting of “coffee grounds” emesis of unknown cause. The patient is very anxious about the source of the bleeding and asks the nurse whether it is possible to find the cause. Which of the following diagnostic tests should the nurse explain can most accurately identify the source of the bleeding?
a. An endoscopy
b. An angiography
c. A gastric analysis
d. Barium contrast studies
ANS: A
| Endoscopy is the primary tool for visualization and diagnosis of upper GI bleeding.
129
What information is most important for the nurse to obtain during the initial assessment of a patient admitted to the emergency department with vomiting of bright-red blood?
a. Current medical problems
b. Medications the patient is taking
c. History of prior bleeding episodes
d. Vital signs and symptoms of hypovolemia
ANS: D
The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute GI bleeding. Blood pressure and pulse are the best indicators of these complications.
130
The physician orders IV vasopressin (Pitressin) to be administered to a patient with esophageal bleeding. The nurse monitors for which of the following during administration of this medication?
a. Polyuria
b. Metabolic alkalosis
c. Intention tremors
d. Chest pain
ANS: D
| Vasopressin decreases coronary artery perfusion and may cause coronary ischemia.
131
The physician orders IV ranitidine (Zantac) every 6 hours for a patient with an acute exacerbation of his chronic peptic ulcer disease. As the nurse administers the drug, the patient asks about it, saying that the only ulcer drug he had been given IV before was cimetidine (Tagamet). In responding to the patient, what should the nurse explain?
a. Both drugs neutralize stomach acid, but ranitidine has fewer side effects than does cimetidine.
b. Ranitidine and cimetidine work the same way to decrease the effect of histamine and decrease acidity.
c. Ranitidine blocks histamine receptors to decrease acid production, but cimetidine acts on the nervous system to decrease gastric motility and secretions.
d. Cimetidine creates a protective pastelike complex covering the ulcer during healing, whereas ranitidine coats the entire stomach and duodenum.
ANS: B
| Ranitidine is an H2-receptor blocker, which decreases the secretion of gastric acid.
132
The family member of a patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine. The nurse will explain that the medication will do which of the following?
a. Decrease the risk for nausea and vomiting.
b. Prevent aspiration of gastric contents.
c. Inhibit the development of stress ulcers.
d. Lower the chance for H. pylori infection.
ANS: C
Famotidine is administered to prevent the development of physiological stress ulcers, which are associated with a major physiological insult such as massive trauma.
133
A patient with a bleeding duodenal ulcer has an NG tube in place, and the physician orders 30 mL of aluminum hydroxide–magnesium hydroxide (Maalox) to be instilled through the tube every hour. How can the nurse evaluate the effectiveness of this treatment?
a. Monitor arterial blood gas values.
b. Check each stool for the presence of occult blood.
c. Periodically aspirate and test stomach contents for pH.
d. Measure the amount of residual stomach contents hourly.
ANS: C
The purpose of antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication.
134
A patient with a peptic ulcer who has an NG tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next?
a. Irrigate the NG tube.
b. Obtain the vital signs.
c. Give the ordered antacid.
d. Listen for bowel sounds.
ANS: B
| The patient’s symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock.
135
A patient undergoes a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. Postoperative orders include morphine with a patient-controlled analgesia (PCA) device and NPO status with low, intermittent NG suction in addition to IV fluids and antibiotics. Twenty four hours after the patient returns to the surgical unit, she complains of increasing abdominal pain. The nursing assessment reveals absence of bowel sounds and 200 mL of bright-red NG drainage in the last hour. What is the most appropriate nursing action?
a. Notify the physician.
b. Irrigate the NG tube per orders.
c. Assess the patient’s use of the PCA.
d. Splint the abdomen to relieve pressure on the incision.
ANS: A
Increased pain and 200 mL of bright-red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion, a return to surgery, or both are needed.
136
The nurse implements discharge teaching for a patient following a gastroduodenostomy for treatment of a peptic ulcer. Which patient statement indicates that the teaching has been effective?
a. “I will need to choose foods that are low in fat and high in carbohydrate.”
b. “I will try to drink liquids along with my meals.”
c. “Vitamin injections may be needed to prevent problems with anemia.”
d. “The surgery has cured my peptic ulcer disease.”
ANS: C
| Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin injections.
137
A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations, with an urge to defecate about 20 minutes after eating. To avoid recurrence of these symptoms, what should the nurse teach the patient to do?
a. Increase fluid intake with meals.
b. Lie down for about 30 minutes after each meal.
c. Drink sugared fluids or eat candy after each meal.
d. Eat a high-carbohydrate, low-fat diet in six small feedings a day.
ANS: B
| The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating.
138
The following orders are received for a patient who has vomited 1500 mL of bright-red blood. Which order will the nurse act on first?
a. Infuse 1000 mL of lactated Ringer’s solution.
b. Administer IV famotidine 40 mg.
c. Insert an NG tube, and connect it to suction.
d. Type and crossmatch for 4 units of packed red blood cells.
ANS: A
Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities.
139
A patient who uses an NSAID for management of severe osteoarthritis has recently developed melena. Which of the following changes in the treatment plan would the nurse expect to be made by the physician?
a. Administration of ranitidine
b. Substitution of corticosteroids for the NSAID
c. Substitution of acetaminophen for the NSAID
d. Administration of misoprostol (Cytotec) with the NSAID
ANS: D
| Misoprostol, a prostaglandin analogue, is the only drug approved for preventing gastric ulcers induced by NSAIDs.
140
The physician prescribes antacids and sucralfate (Carafate) for treatment of a patient’s peptic ulcer. To promote the effects of these drugs, what should the nurse teach the patient to take?
a. Sucralfate and antacids together 30 minutes before each meal
b. Antacids every 2 hours while awake and sucralfate at bedtime
c. Antacids 1 hour before each meal and sucralfate between meals
d. Sucralfate 30 minutes before each meal and antacids 1 and 3 hours after meals and at bedtime
ANS: D
Sucralfate is most effective when the pH is low and should not be given with or soon after an antacid. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective.
141
In teaching a patient with peptic ulcer disease about nutritional management of the disorder, what should the nurse stress that the patient should do?
a. Avoid raw fruits and vegetables.
b. Avoid foods that cause discomfort.
c. Eat six small meals a day with bland foods.
d. Eliminate milk and milk products from the diet.
ANS: B
| The best information is that each individual should choose foods that are not associated with postprandial discomfort.
142
A patient with acute GI bleeding is receiving normal saline IV at a rate of 500 mL/hour. Which of the following assessment data obtained by the nurse are most important to communicate immediately to the physician?
a. The NG suction is returning “coffee grounds” material.
b. The patient’s lungs have crackles audible to the midline.
c. The patient’s blood pressure has increased to 142/94 mm Hg.
d. The bowel sounds are very hyperactive in all four quadrants.
ANS: B
The patient’s lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed.
143
A 68-year-old patient has had intermittent epigastric distress, anorexia, and weight loss over a period of 6 months. She is hospitalized with anemia and ascites, and an endoscopic examination reveals cancer located in the fundus of the stomach. The nurse plans care for the patient with the knowledge that these findings indicate which of the following?
a. The patient has a poor prognosis with any therapy.
b. Surgical intervention is not indicated for the patient.
c. Radiation therapy is the treatment of choice for the patient.
d. The patient has a good prognosis with the use of combination chemotherapy.
ANS: A
The survival rate for patients with stomach cancer is low, and the presence of ascites indicates metastasis and is a poor prognostic sign.
144
Which of the following foods are associated with an increased incidence of gastric cancer that the nurse should specifically question the patient about when obtaining a nursing history?
a. Milk and milk products
b. Raw fruits and vegetables
c. Smoked, highly salted, or spiced foods
d. Beans and other gas-forming foods
ANS: C
Smoked foods such as bacon, ham, and smoked sausage, highly salted foods, and spiced foods increase the risk for stomach cancer.
145
Which agent that causes bacterial food poisoning is known to have the quickest onset of symptoms?
a. Listeria
b. Escherichia coli
c. Clostridium botulinum
d. Staphylococcus aureus
ANS: D
| S. aureus has the quickest onset of symptoms, as early as 30 minutes to 7 hours after ingestion.
146
A patient tells the nurse that she frequently buys canned foods at a discount price because they are dented. She asks if there is a way to prevent food poisoning from using improperly canned products. Which of the following would be the nurse’s best response?
a. Discard the canned food if the smell is abnormal.
b. Boil the canned food for 15 minutes before serving.
c. There is no known way to prevent food poisoning from improperly canned foods.
d. Open the cans immediately after purchase, and place the contents in plastic containers in the freezer for 48 hours.
ANS: B
| If there is suspicion that the food is improperly canned, it should be boiled for at least 15 minutes before serving
147
The nurse suspects the possibility of E. coli food poisoning when several individuals eating at the same establishment develop the onset of which of the following symptoms?
a. Fever and chills
b. Nausea and vomiting
c. Hemorrhagic diarrhea
d. Headache, dizziness, and muscular incoordination
ANS: C
| E. coli O157:H7 causes hemorrhagic colitis with bloody diarrhea.
