PT 5

49問 • 1年前

問題一覧

Which electrocardiographic (ECG) change is most important for the nurse to report to the health care provider when caring for a patient with chest pain?

ST segment elevation

When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate the need for immediate action by the nurse?

Report of severe chest pain

A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which nursing diagnosis is a priority for the patient?

Decreased cardiac output related to cardiogenic shock

When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first?

Attach the heart monitor.

Which information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction is most important for the nurse to communicate to the health care provider

No change in the patient's reported level of chest pain

The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider?

Bilateral crackles in the mid-lower lobes.

A patient had a non-ST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

Reinforcement of teaching about the purpose of prescribed medications

A patient who has chest pain is admitted to the emergency department (ED), and all of the following are ordered. Which one should the nurse arrange to be completed first?

Electrocardiogram (ECG)

After receiving change-of-shift report about the following four patients on the cardiac care unit, which patient should the nurse assess first?

A 59-yr-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI)

To improve the physical activity level for a mildly obese 71-yr-old patient, which action should the nurse plan to take?

Determine what kind of physical activities the patient usually enjoys.

Which patient at the cardiovascular clinic requires the most immediate action by the nurse?

Patient with stable angina whose chest pain has recently increased in frequency

A patient with diabetes mellitus and chronic stable angina has a new order for captopril . The nurse should teach the patient that the primary purpose of captopril is to

prevent changes in heart muscle.

After reviewing information shown in the accompanying figure from the medical records of a 43-yr-old patient, which risk factor modification for coronary artery disease should the nurse include in patient teaching?

Dietary changes to improve lipid levels

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider?

Bilateral crackles

The nurse obtains a health history from an older patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most focused on identifying a risk factor for IE?

"Have you had dental work done recently?"

During the assessment of a young adult patient with infective endocarditis (IE), the nurse would expect to find

A new regurgitant murmur

The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)

Urine output less than 30 mL/hr

When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is most appropriate for the nurse to include?

Arrange for placement of a long-term IV catheter

A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of

echocardiography

To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should

auscultate by placing the diaphragm of the stethoscope on the lower left sternal border.

The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should

note when Korotkoff sounds are auscultated during both inspiration and expiration.

The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. An appropriate intervention by the nurse for this problem is to

place the patient in Fowler's position, leaning forward on the overbed table.

The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history focuses on a pertinent risk factor for rheumatic fever?

"Have you had a recent sore throat?"

A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. The patient reports that discomfort in the joints prevents favorite activities such as taking a daily walk and working on sewing projects. Based on these findings, which nursing diagnosis statement would be appropriate?

Activity intolerance related to arthralgia

The home health nurse is visiting a 30-yr-old patient recovering from rheumatic fever without carditis. The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge regarding long-term management of rheumatic fever when the patient makes which statement?

"I will be immune to future episodes of rheumatic fever after this infection."

When developing a community health program to decrease the incidence of rheumatic fever, which action should the community health nurse include

Teach community members to seek treatment for streptococcal pharyngitis.

When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for

shortness of breath on exertion

A 21-yr-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient?

Lifelong anticoagulant therapy is needed after mechanical valve replacement.

While caring for a 23-yr-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to

avoid over-the-counter (OTC) drugs that contain stimulants.

While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. An appropriate nursing intervention for this patient would be to

promote rest to decrease myocardial oxygen demand.

During discharge teaching with an older patient who had a mitral valve replacement with a mechanical valve, the nurse must instruct the patient on the

need for frequent laboratory blood testing.

A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which prescribed PRN medication will be the most appropriate for the nurse to give?

Oral ibuprofen (Motrin) 600 mg

When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of

shortness of breath

A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient about managing this disorder?

Notify the doctor about any symptoms of heart failure such as shortness of breath.

The nurse is obtaining a health history from a 24-yr-old patient with hypertrophic cardiomyopathy (CMP). Which information obtained by the nurse is most important?

The patient's 29-yr-old brother died from a sudden cardiac arrest

The nurse will plan discharge teaching about prophylactic antibiotics before dental procedures for which patient?

Patient who had a mitral valve replacement with a mechanical valve

Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement?

Order blood cultures drawn from two sites.

Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider?

Sudden onset right flank pain

Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider?

Jugular venous distention (JVD) to jaw level

The nurse is caring for a patient with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider

The patient complains of chest pressure when ambulating.

Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first?

Auscultate the heart sounds.

The nurse is caring for a 64-yr-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately

The patient has diffuse bilateral crackles

Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are most effective?

Assess for the presence of jugular venous distention (JVD).

Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge teaching about self-management has been effective

"I will take antibiotics before my teeth are cleaned at the dental office.

The nurse is assessing a patient with myocarditis before giving the scheduled dose of digoxin (Lanoxin)

Irregular pulse

After receiving change-of-shift report on four patients, which patient should the nurse assess first?

Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg

After receiving information about four patients during change-of-shift report, which patient should the nurse assess first?

Patient who has just returned to the unit after balloon valvuloplasty

Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit?

Watch the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.

The nurse is caring for a patient with mitral regurgitation. Referring to the figure below, where should the nurse listen to best hear a murmur typical of mitral regurgitation?

mid sternal 5th intercostal

study

ユーザ名非公開 · 61問 · 1年前

study