100%VERIFIED ANSWERSA+GRADED
ALREADY PASSED!!!!
You are reviewing the chart of a PT who is receiving heparin therapy for a DVT. Which
intervention should the RN anticipate taking if the PTs aPTT is 96 seconds?
1. Increase heparin infusion rate by 2mL/hr
2. Continue monitor the heparin infusion as prescribed
3. Request a prothrombin time PT
4. Stop the heparin infusion - correct answer...✔✔4. Stop the heparin infusion- pt is
above the therapeutic range of 1-5-2 times the control. should discontinue to prevent
harm
You are providing teaching to a PT who is 2 days post op following a heart transplant.
Which following statements should the nurse include in the teaching?
1. You may no longer be able to feel chest pain
2. Your level of activity intolerance will not change
3. after 6 months you will no longer need to restrict you Na
4. You will be able to stop taking immunosuppressants after 12 months - correct
answer...✔✔1. You may no longer be able to feel chest pain- transplant PTs no longer
feel chest pain due to denervation of the heart
ER nurse is assessing PT with bradydysrhythmia. Which finding should he expect?
1. Confusion
2. Friction Rub
3. HTN
4. Dry skin - correct answer...✔✔1. Confusion- as a result of decreased tissue
perfusion
You are caring for a PT who had an anterior MI. PTs hx shows she is 1 wk post op open
cholecystectomy the RN knows that which intervention is contraindicated?
1. Administering IV morphine
2. giving O2 at 2L NC
3. Helping client to BSC
4. Assisting in thrombolytic therapy - correct answer...✔✔4. Assisting in thrombolytic
therapy- having surgery within 3 wks is a contraindication for thrombolytic therapy
You are caring for a PT who has endocarditis. Which finding should you recognize as a
complication?
AGRADESOLUTIONS
,1. Ventricular depolarization
2. Guillain Barre Syndrome
3. Myelodysplastic syndrome
4. Valvular disease - correct answer...✔✔4. Valvular disease- damage will occur as a
result of inflammation or infection of the endocardium
You are caring for PT with BP of 254/139, you recognize the PT is in a hypertensive
crisis. Which action should you take first?
1. Obtain blood samples for testing
2. Tell the PT to report vision changes
3. Place HOB at 45 degrees
4. Initiate IV access - correct answer...✔✔3. Place HOB at 45 degrees-ABC's this will
promote respiratory status and promote venous return reducing workload on heart
**Initiate IV access- not first action
When performing a cardiac assessment what is the point of maximal impulse?
1. 2nd intercostal space right to the sternum
2. 2nd intercostal space left to the sternum
3. 5th intercostal space to the left of thermal border
4. Left 5th intercostal space in the midclavicular line - correct answer...✔✔4. Left 5th
intercostal space in the midclavicular line-this is best to hear the apex of the heart which
is considered maximal impulse
You are caring for a PT who is experiencing Afib. You should report what finding to the
provider?
1. Slurred speech
2. Irregular pulse
3. Dependent edema
4. Persistant fatigue - correct answer...✔✔1. Slurred speech- greatest risk is an
embolus and this can indicate embolus
You are assessing a PT with Left sided heart failure. What manifestation should you
expect to find?
1. Increased abdominal girth
2. Weak peripheral pulses
3. Jugular venous neck distention
4. Dependent edema - correct answer...✔✔2. Weak peripheral pulses- r/t decreased
CO from LSHF
AGRADESOLUTIONS
, You are caring for a PT who is being treated for HF and has prescriptions for digoxin
and furosemide. You plan to monitor for which of the following as an adverse effect of
these meds?
1. SOB
2. Lightheadedness
3. Dry cough
4. Metallic taste - correct answer...✔✔2. Lightheadedness- can cause a sudden drop in
BP= lightheadedness
You are monitoring a PT following coronary bypass graft surgery (CABG). Which finding
indicates cardiac tamponade?
1. Sternal instability
2. Increased WBC count
3. BP of 140/82 on inspiration and 154/90 on expiration
4. Sinus rhythm with occasional premature atrial contractions and HR 88 - correct
answer...✔✔3. BP of 140/82 on inspiration and 154/90 on expiration= pulses
paradoxus
What is Pulsus Paradoxus? - correct answer...✔✔When the systolic BP is 10 points
higher on expiration than on inspiration
**This is indicative of cardiac tamponade
You are preparing PT for coronary angiography. You should report what finding to the
provider prior to procedure?
1. Hgb 14.4
2. HX: PAD peripheral arterial disease
3. UOP of 200ml in 4 hr
4. Previous allergic reaction to shell fish - correct answer...✔✔4. Previous allergic
reaction to shell fish- shellfish reaction will often react to iodine
You are caring for a PT following insertion of a permanent pacemaker. Which PT
statement indicates a potential complication of the insertion procedure?
1. I can't get rid of these hiccups
2. I feel dizzy when i stand
3. My incision stings
4. i have a headache - correct answer...✔✔1. I can't get rid of these hiccups-can
indicate the pacemaker is stimulating the chest wall or diaphragm indicating wire lead
perforation
You are providing discharge teaching to a PT who has a prescription for the transdermal
nitroglycerin patch. Which instruction would you include?
AGRADESOLUTIONS