FINAL EXAM - PNR 309 - CAD, PAD, MI, Stroke, TIA,
Diabetes, Visual And Auditory Disorders,
Neurological Disorders Rated A+
The nurse is scheduling a client for a cardiac catheterization. The client has type
2 diabetes and takes metformin. Which action will the nurse take prior to
scheduling the procedure?
a. The nurse will instruct the client to have a fasting A1C snd glucose tolerence
test prior to the procedure
b. The nurse will instruct the client to eat low carbohydrate diet three days prior
to the procedure
c. The nurse will instruct the client to hold the metformin for 24 hours before the
procedure and 48 hours after the procedure
d. The nurse instructs the client to take all medications the morning of the
procedure but not eat or drink afterwards. - ANSWER c. The nurse will instruct
the client to hold the metformin for 24 hours before the procedure and 48 hours
after the procedure
Rationale:
Metformin is an oral antidiabetic medication used for treatment of diabetes
mellitus type 2, when lifestyle changes and weight loss has not adequately
lowered the blood glucose. The nurse should teach the client to hold the
metformin for 24 hours before the procedure and 48 hours after any procedure.
This is due to the risk of lactic acidosis associated with the combination of
anesthesia and/or contrast medium with metformin. The contrast medium may
affect kidney function, and metformin in the system may increase risk of lactic
acidosis. Holding the drug 24 hours prior and 48 hours following the procedure
will minimize complications.
- nstructing the client to have a fasting A1C and glucose tolerance test prior to
the procedure is not necessary nor the priority.
- although eating a low-carbohydrate, 1800-calorie American Diabetic
Association diet is always important for a diabetic, the most important action for
the nurse to take is teaching how to take metformin.
The nurse is caring for a young adult client following a balloon valvuloplasty of
the aortic valve. During the post-procedure assessment, the nurse monitors for
which complications related to valvuloplasty? Select all that apply.
a. Sudden cardiac arrhythmia
,b. Emboli
c. Sudden mental status changes
d. Redness near the radial vein access site
e. Stroke - ANSWER a. Sudden cardiac arrhythmia
b. Emboli
c. Sudden mental status changes
e. Stroke
Complication of valvuloplasty is a sudden cardiac arrhythmia such as atrial
fibrillation and heart block are risk factors, along with emboli. Therefore,
coagulation therapy may be required postoperatively. Sudden mental status
changes such as delirium may occur following post-procedure which may result
from higher microembolic load, neuroinflammation in the brain, cerebral
hypoperfusion, and alteration of cerebral acetylcholine levels. Nursing actions
should include frequent reorientation strategies and neuro assessments
immediately post-operatively.
- redness near the venous access site is incorrect since the access is arterial
not venous. The most common site is the femoral artery.
The nurse received report from the cardiac catheterization team following a
percutaneous coronary intervention (PCI) procedure. During the assessment,
the nurse notices a blood-soaked dressing and bleeding from the femoral artery
access site. What action should the nurse perform first?
a. Add another dressing layer on top of the saturated dressing.
b. Raise the leg and place the client in trendelenberg position
c. Call for help and apply pressure to the site immediately
d. Immediately pull on the femoral sheath until it is out of the femoral site. -
ANSWER c. Call for help and apply pressure to the site immediately
Rationale:
Hemorrhage is excessive bleeding that can lead to shock and death. It is
especially a risk if the client is bleeding from an artery since arteries are high
pressured vessels directly coming from the heart. The major sign of bleeding or
hemorrhage from an artery is obvious external bleeding noted on bandages or
hard, indurated areas near the site, such as the board-like abdomen for
abdominal hemorrhage. The client will quickly experience shock from arterial
bleeding, including decreasing blood pressure, increasing heart rate,
decreasing level of consciousness, and cool extremities. Quick action by the
nurse, including calling for help and applying pressure to the site immediately is
necessary to keep the client alive.
- Adding another dressing layer on top of the saturated dressing of an arterial
site will not stop the bleeding and delay important life-saving actions.
,- Raising the lower extremity or placing the client in trendelenburg will not stop
the bleeding. Sometimes this is used to elevate the blood pressure, but never
before other actions to stop the bleeding have occurred.
- Increased bleeding and possible hemorrhage may occur if the femoral sheath
is pulled out.
The nurse is caring for a client with severe left ventricular dysfunction and
understands the client is at risk for sudden cardiac death. The nurse anticipates
which medical intervention?
a. Insertion of an implantable cardioverter defibrillator
b. Insertion of an implantable atrial pacemaker
c. Administration of thrombolytic agents
d. Cardioversion under light anesthesia - ANSWER a. Insertion of an implantable
cardioverter defibrillator
Rationale:
A client with left ventricular dysfunction is at increased risk of sudden cardiac
death related to lethal cardiac rhythms. Therefore, use of an implantable
cardioverter defibrillator (ICD) provides significant survival benefit since it
monitors the heart rhythm, detects irregular heart rhythms, and delivers a
shock, if needed.
- an atrial pacemaker is not needed. Something that addresses the problems
associated with a ventricular problem, including ventricular tachycardia or
ventricular fibrillation, which are lethal arrhythmias that need to be shocked
with a defibrillator.
- administration of thrombolytic agents is not indicated since the client does not
have a known clot with left ventricular dysfunction. With left ventricular
dysfunction, the left ventricle does not contract effectively enough to pump
blood to perfuse the body and give adequate cardiac output.
- cardioversion under light anesthesia is not a treatment for ventricular
dysfunction and sudden cardiac death risk.
The nurse is preparing an individualized education plan for a client who has a
history of smoking and is two days post-cardiac surgery. Which information best
addresses client education as an intervention for the nursing diagnosis of
ineffective airway clearance related to pulmonary secretions?
a. Client teach-back on low sodium diet
b. Client teaching and demonstration of self-injection enoxaparin
c. Client teaching on the need for weekly PTT and INR foe enoxaparin therapy
d. Client teaching and demonstration of deep breathing and coughing exercises.
- ANSWER d. Client teaching and demonstration of deep breathing and coughing
exercises.
, Rationale:
Ineffective airway clearance is the difficulty or inability to clear or remove
pulmonary secretions or excretions from the airway or bronchi. Being able to
keep the airway patent is vital to life. A history of smoking can increase the risk
of being unable to clear secretions from the airway. Ineffective airway clearance
is characterized by dyspnea, excess secretions, ineffective or no cough,
cyanosis, abnormal respirations, and adventitious (abnormal) breath sounds.
Following any heart or chest surgery, the client will be at more risk for breathing
difficulties, especially with a history of smoking. The client should be taught and
produce return demonstration about deep breathing and coughing exercises to
help produce a patent airway with adequate gas exchange.
- although a low sodium diet is important for this client, it does not address the
nursing diagnosis of ineffective airway clearance related to pulmonary
secretions.
- teaching and demonstration of self-injection of enoxaparin is related to
decreasing deep vein thrombosis, not ineffective airway clearance related to
pulmonary secretions.
- teaching on the need for weekly PTT and INR for enoxaparin therapy is not
needed and does not address the nursing diagnosis of ineffective airway
clearance related to pulmonary secretions.
A client is admitted for observation following complaints of intermittent chest
pain while mowing the grass. The pain persisted for an hour following the
activity. All cardiac labs, electrocardiogram, and radiologic studies were normal
and the client was provided nitroglycerin for a new diagnosis of angina pectoris.
Discharge education includes information that angina is most often attributable
to what cause?
a. Decreased workload on the heart
b. Atrial septal defect
c. Infarction of the myocardium
d. Coronary arteriosclerosis - ANSWER d. Coronary arteriosclerosis
Rationale:
Arteriosclerosis is the most common cause of angina pectoris (chest pain)
because of narrowing of vessels that carry oxygen and nutrients from the heart
to the rest of the bodies. Diminished oxygen from reduced blood flow in arteries
supplying the heart muscle causes chest pain (angina pectoris).
- decreased workload of the heart is not the most attributable cause of angina
pectoris (chest pain).
- septal defects are not a common cause of angina.
- chest pain that is unrelieved may progress to myocardial infarction from
sudden rupture of plaque or obstruction of blood flow. Arteriosclerosis is the
Diabetes, Visual And Auditory Disorders,
Neurological Disorders Rated A+
The nurse is scheduling a client for a cardiac catheterization. The client has type
2 diabetes and takes metformin. Which action will the nurse take prior to
scheduling the procedure?
a. The nurse will instruct the client to have a fasting A1C snd glucose tolerence
test prior to the procedure
b. The nurse will instruct the client to eat low carbohydrate diet three days prior
to the procedure
c. The nurse will instruct the client to hold the metformin for 24 hours before the
procedure and 48 hours after the procedure
d. The nurse instructs the client to take all medications the morning of the
procedure but not eat or drink afterwards. - ANSWER c. The nurse will instruct
the client to hold the metformin for 24 hours before the procedure and 48 hours
after the procedure
Rationale:
Metformin is an oral antidiabetic medication used for treatment of diabetes
mellitus type 2, when lifestyle changes and weight loss has not adequately
lowered the blood glucose. The nurse should teach the client to hold the
metformin for 24 hours before the procedure and 48 hours after any procedure.
This is due to the risk of lactic acidosis associated with the combination of
anesthesia and/or contrast medium with metformin. The contrast medium may
affect kidney function, and metformin in the system may increase risk of lactic
acidosis. Holding the drug 24 hours prior and 48 hours following the procedure
will minimize complications.
- nstructing the client to have a fasting A1C and glucose tolerance test prior to
the procedure is not necessary nor the priority.
- although eating a low-carbohydrate, 1800-calorie American Diabetic
Association diet is always important for a diabetic, the most important action for
the nurse to take is teaching how to take metformin.
The nurse is caring for a young adult client following a balloon valvuloplasty of
the aortic valve. During the post-procedure assessment, the nurse monitors for
which complications related to valvuloplasty? Select all that apply.
a. Sudden cardiac arrhythmia
,b. Emboli
c. Sudden mental status changes
d. Redness near the radial vein access site
e. Stroke - ANSWER a. Sudden cardiac arrhythmia
b. Emboli
c. Sudden mental status changes
e. Stroke
Complication of valvuloplasty is a sudden cardiac arrhythmia such as atrial
fibrillation and heart block are risk factors, along with emboli. Therefore,
coagulation therapy may be required postoperatively. Sudden mental status
changes such as delirium may occur following post-procedure which may result
from higher microembolic load, neuroinflammation in the brain, cerebral
hypoperfusion, and alteration of cerebral acetylcholine levels. Nursing actions
should include frequent reorientation strategies and neuro assessments
immediately post-operatively.
- redness near the venous access site is incorrect since the access is arterial
not venous. The most common site is the femoral artery.
The nurse received report from the cardiac catheterization team following a
percutaneous coronary intervention (PCI) procedure. During the assessment,
the nurse notices a blood-soaked dressing and bleeding from the femoral artery
access site. What action should the nurse perform first?
a. Add another dressing layer on top of the saturated dressing.
b. Raise the leg and place the client in trendelenberg position
c. Call for help and apply pressure to the site immediately
d. Immediately pull on the femoral sheath until it is out of the femoral site. -
ANSWER c. Call for help and apply pressure to the site immediately
Rationale:
Hemorrhage is excessive bleeding that can lead to shock and death. It is
especially a risk if the client is bleeding from an artery since arteries are high
pressured vessels directly coming from the heart. The major sign of bleeding or
hemorrhage from an artery is obvious external bleeding noted on bandages or
hard, indurated areas near the site, such as the board-like abdomen for
abdominal hemorrhage. The client will quickly experience shock from arterial
bleeding, including decreasing blood pressure, increasing heart rate,
decreasing level of consciousness, and cool extremities. Quick action by the
nurse, including calling for help and applying pressure to the site immediately is
necessary to keep the client alive.
- Adding another dressing layer on top of the saturated dressing of an arterial
site will not stop the bleeding and delay important life-saving actions.
,- Raising the lower extremity or placing the client in trendelenburg will not stop
the bleeding. Sometimes this is used to elevate the blood pressure, but never
before other actions to stop the bleeding have occurred.
- Increased bleeding and possible hemorrhage may occur if the femoral sheath
is pulled out.
The nurse is caring for a client with severe left ventricular dysfunction and
understands the client is at risk for sudden cardiac death. The nurse anticipates
which medical intervention?
a. Insertion of an implantable cardioverter defibrillator
b. Insertion of an implantable atrial pacemaker
c. Administration of thrombolytic agents
d. Cardioversion under light anesthesia - ANSWER a. Insertion of an implantable
cardioverter defibrillator
Rationale:
A client with left ventricular dysfunction is at increased risk of sudden cardiac
death related to lethal cardiac rhythms. Therefore, use of an implantable
cardioverter defibrillator (ICD) provides significant survival benefit since it
monitors the heart rhythm, detects irregular heart rhythms, and delivers a
shock, if needed.
- an atrial pacemaker is not needed. Something that addresses the problems
associated with a ventricular problem, including ventricular tachycardia or
ventricular fibrillation, which are lethal arrhythmias that need to be shocked
with a defibrillator.
- administration of thrombolytic agents is not indicated since the client does not
have a known clot with left ventricular dysfunction. With left ventricular
dysfunction, the left ventricle does not contract effectively enough to pump
blood to perfuse the body and give adequate cardiac output.
- cardioversion under light anesthesia is not a treatment for ventricular
dysfunction and sudden cardiac death risk.
The nurse is preparing an individualized education plan for a client who has a
history of smoking and is two days post-cardiac surgery. Which information best
addresses client education as an intervention for the nursing diagnosis of
ineffective airway clearance related to pulmonary secretions?
a. Client teach-back on low sodium diet
b. Client teaching and demonstration of self-injection enoxaparin
c. Client teaching on the need for weekly PTT and INR foe enoxaparin therapy
d. Client teaching and demonstration of deep breathing and coughing exercises.
- ANSWER d. Client teaching and demonstration of deep breathing and coughing
exercises.
, Rationale:
Ineffective airway clearance is the difficulty or inability to clear or remove
pulmonary secretions or excretions from the airway or bronchi. Being able to
keep the airway patent is vital to life. A history of smoking can increase the risk
of being unable to clear secretions from the airway. Ineffective airway clearance
is characterized by dyspnea, excess secretions, ineffective or no cough,
cyanosis, abnormal respirations, and adventitious (abnormal) breath sounds.
Following any heart or chest surgery, the client will be at more risk for breathing
difficulties, especially with a history of smoking. The client should be taught and
produce return demonstration about deep breathing and coughing exercises to
help produce a patent airway with adequate gas exchange.
- although a low sodium diet is important for this client, it does not address the
nursing diagnosis of ineffective airway clearance related to pulmonary
secretions.
- teaching and demonstration of self-injection of enoxaparin is related to
decreasing deep vein thrombosis, not ineffective airway clearance related to
pulmonary secretions.
- teaching on the need for weekly PTT and INR for enoxaparin therapy is not
needed and does not address the nursing diagnosis of ineffective airway
clearance related to pulmonary secretions.
A client is admitted for observation following complaints of intermittent chest
pain while mowing the grass. The pain persisted for an hour following the
activity. All cardiac labs, electrocardiogram, and radiologic studies were normal
and the client was provided nitroglycerin for a new diagnosis of angina pectoris.
Discharge education includes information that angina is most often attributable
to what cause?
a. Decreased workload on the heart
b. Atrial septal defect
c. Infarction of the myocardium
d. Coronary arteriosclerosis - ANSWER d. Coronary arteriosclerosis
Rationale:
Arteriosclerosis is the most common cause of angina pectoris (chest pain)
because of narrowing of vessels that carry oxygen and nutrients from the heart
to the rest of the bodies. Diminished oxygen from reduced blood flow in arteries
supplying the heart muscle causes chest pain (angina pectoris).
- decreased workload of the heart is not the most attributable cause of angina
pectoris (chest pain).
- septal defects are not a common cause of angina.
- chest pain that is unrelieved may progress to myocardial infarction from
sudden rupture of plaque or obstruction of blood flow. Arteriosclerosis is the
