PT 4

53問 • 1年前

問題一覧

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?

Inversion of T waves on the electrocardiogram

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?

The patient is allergic to shellfish.

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?

Place the patient on NPO status.

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?

Attaching ECG monitoring electrodes after a patient bathes

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?

High troponin I level

While listening at the mitral area, the nurse notes abnormal heart sounds at the patient's fifth intercostal space, midclavicular line. After listening to the audio clip, describe how the nurse will document the assessment finding

Systolic murmur noted at mitral area

Which term describes what determines afterload?

arterial pressure

Which diagnosis does rest pain indicate?

arterial occlusion

A patient has a history of crushing chest pain, dyspnea, and diaphoresis. Which diagnostic test will be performed to provide the most detailed information regarding heart function?

Cardiac catheterization

A patient has been having episodes of syncope that occur one or two times a week. Which monitoring device will most likely identify an underlying dysrhythmia?

Loop recorder

A patient presents to the emergency department reporting severe, crushing chest pain. The health care provider suspects an acute myocardial infarction. Which laboratory test result will the nurse check to help confirm this diagnosis?

Troponin T

Which age-related changes are expected in the cardiovascular system?

Heart takes longer to respond to stress or exercise

A patient diagnosed with angina is being discharged. The patient will be taking nitroglycerin at home. Which teaching should the nurse reinforce about the nitroglycerin tablets?

place it under the tongue

Which priority action should the nurse take when caring for a patient who just returned from a pacemaker insertion?

Immobilize the arm

Which statement describes the relationship between cardiac output and stroke volume? (Select all that apply.)

Cardiac output is the product of the stroke volume and heart rate., injury or illness such as a heart attack can affect the contractility and therefore the cardiac output and stroke volume, Stroke volume is the amount of blood ejected with each ventricular contraction, Cardiac output is normally 4 to 8 L/min.

Which lesion is the earliest to develop in atherosclerosis?

fatty streak

Which information will the nurse typically expect to hear from the patient diagnosed with stable angina?

My chest pain is relieved with nitroglycerin.

Which is the most frequent cause of death after an MI

cardiogenic shock

The LPN/LVN is caring for a patient with an acute MI. Which ECG changes would be expected if the patient had prolonged total occlusion of a coronary artery?

ST segment elevation

Which nursing intervention is the priority with the administration of digoxin?

Count the apical pulse for 1 full minute before each dose

Which therapeutic dietary measure is the most common for chronic heart failure

sodium restriction

The LPN/LNV is caring for a diabetic patient who is overweight. The patient is also a long-time smoker. Which risk factors for atherosclerosis are modifiable in this patient? (Select all that apply.)

obesity, smoking, diabetes

Which nursing interventions are the priority when caring for a patient with acute MI? (Select all that apply.)

Pain relief, Oxygenation, Anxiety relief

Which signs and symptoms are typical and expected for a patient with right-sided heart failure? (Select all that apply.)

Jugular vein distention, Dependent edema C, Fatigue

When developing a teaching plan for a 61-yr-old patient with multiple risk factors for coronary artery disease (CAD), the nurse should focus primarily on the

Elevated low-density lipoprotein (LDL) level

Which nursing intervention is likely to be most effective when assisting the patient with coronary artery disease to make appropriate dietary changes?

Help the patient modify favorite high-fat recipes by using monounsaturated oils.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is caused by an acute myocardial infarction (AMI)?

The pain has lasted longer than 30 minutes.

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

"The pain goes away after a nitroglycerin tablet."

After the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective?

"I will call an ambulance if I still have pain after taking three nitroglycerin 5 minutes apart."

Which statement made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed?

"I will miss being able to eat peanut butter sandwiches."

After the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective?

"It is important not to suddenly stop taking the carvedilol."

A patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to best determine whether the patient has had an AMI?

Cardiac-specific troponin

Diltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that diltiazem will

decrease coronary artery spasms.

The nurse suspects that the patient with stable angina is experiencing a side effect of the prescribed drug metoprolol (Lopressor) if the

blood pressure is 90/54 mm Hg.

Nadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor for

Participation in daily activities without chest pain

Heparin is ordered for a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin?

Heparin prevents the development of new clots in the coronary arteries.

When titrating IV nitroglycerin for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the drug?

Ask about chest pain

A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction. Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy

"What time did your chest pain begin?"

After an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse evaluates the patient's response to the activity, which data would indicate that the exercise level should be decreased?

Heart rate increases from 66 to 98 beats/min.

During the administration of the thrombolytic agent to a patient with an acute myocardial infarction, the nurse should stop the drug infusion if the patient experiences

a decrease in level of consciousness

A patient recovering from a myocardial infarction (MI) develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take as focused follow-up on this symptom?

Auscultate for a pericardial friction rub.

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective?

"I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."

Three days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, "I am too nervous about my heart to be alone while I get washed up." Based on this information, which nursing diagnosis is appropriate?

Anxiety related to change in health status

When caring for a patient who is recovering from a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient that

additional diagnostic testing will be required

A few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, "It was just a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which reply would be most appropriate for the nurse to make?

What do you think caused your chest pain?

When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following?

I will have small incisions in my leg where they will remove the vein

A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse when sexual intercourse can be resumed. Which response by the nurse is best?

"Sexual activity uses about as much energy as climbing two flights of stairs."

A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when scheduling this medication

Give the patient's other medications 2 hours after colesevelam.

The nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would include

when cardiac rehabilitation will begin.

A patient who has recently started taking pravastatin (Pravachol) and niacin reports several symptoms to the nurse. Which information is most important to communicate to the health care provider?

Generalized muscle aches and pains

A patient who is being admitted to the emergency department with intermittent chest pain gives the following list of daily medications to the nurse. Which medication has the most immediate implications for the patient's care?

sildenafil (Viagra)

Which assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider?

Pallor and weakness of the right hand

When caring for a patient who has just arrived on the telemetry unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?

Give the scheduled aspirin and lipid-lowering medication.

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