FINAL EXAM - PNR 309 - CAD, PAD, MI,
Stroke, TIA, Diabetes, Visual and
Auditory Disorders, Neurological
disorders All Questions Solved Correct.
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.
,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.
,- 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
, 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).
Stroke, TIA, Diabetes, Visual and
Auditory Disorders, Neurological
disorders All Questions Solved Correct.
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.
,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.
,- 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
, 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).
