Med Surg Capstone Quizzes With Complete Solutions

You are a nurse starting your shift. You are doing a bedside report with the off-going nurse, when you realize that the patient's peripheral IV site looks sort of shiny. You check for a blood return, and find there is none. Plus, you have difficulty flushing. The patient states that the IV burns when you flush it. The NEXT thing you do is: - ANSWER Find out what was running through the IV; if it was a vesicant, then the IV will need immediate care You have just assumed care of King Valium, a new patient to your floor. He has a history of IV drug abuse, and is admitted with endocarditis. The off-going nurse reported to you that Mr. Valium has had fevers up to 103.4, has been alternating between chilling and sweating, and is complaining of feeling terrible. She attempted to start an IV, but was unsuccessful, so the patient has not yet had his first dose of IV antibiotic. You know that the first thing you will need to do for Mr. Valium is: - ANSWER Assess the patient's arms for a possible IV spot. If there is a good spot, start the IV. If there is not, then call in more experienced help. You are doing bedside report of a patient that is receiving a set rate of "renal dose dopamine". You notice that this is running via a peripheral IV. The next thing you do is: - ANSWER Check the IV site for signs of infiltration John Deer is a 48-year old male who just had a leg amputation performed 24 hours ago. He is having excruciating pain and requests some pain medication. You bring the Morphine 2 mg to his room to give him IVP, as ordered. Before administering the medication to the patient, you assess his RIJ central line, and find that it will flush, but there is no blood return from the first port you check. The NEXT thing you will do is: - ANSWER Reposition the patient and check again for blood return. A patient who was involved in a high-speed motor vehicle crash has just arrived in the ED. You are the nurse who will be placing the IV catheter. You choose which size catheter? - ANSWER 18 g because blood and IVF will need to be administered quickly According to Crimlisk, Johnstone, and Sanchez (2009), the mnemonic CATS PRRR helps nurses remember to routinely check IV medications for: - ANSWER Compatibilities, allergies, tubing correct, site checked, pump safety checked, right rate, release clamps, return and reassess the patient. A patient is scheduled to get a unit of Packed Red Blood Cells (PRBCs) because of anemia of chronic disease. What is the smallest sized IV catheter that can be used in this patient to administer the blood? - ANSWER 22 g Nurse Ned is going to give his patient Pantoprazole, 20mg IV push. He has already checked to verify that: Pantoprazole is compatible with the running IV fluids, his patient is not allergic to Pantoprazole, the IV tubing is current and has an IV push access, and that the site is OK and patent. Nurse Ned has also made sure that the pump running the IV fluids is working properly, and has verified and calculated how quickly he will give the Pantoprazole. Nurse Ned administered the Pantoprazole, and is preparing to move on to his next task. Before Nurse Ned leaves this patient, what should he do next? - ANSWER Release Tubing Clamps A patient comes into the Emergency Department with abdominal pain. The nurse has orders to start IV fluids and draw labs. The nurse inserts an 18 g IV into the patient's right antecubital area, and immediately draws a "rainbow" of blood tubes that get sent to lab. As soon as the nurse is finished collecting the labs, she flushes the blood out of the line, hooks the IV fluids into the IV, and sets the pump for the proper rate. The nurse did not formally check the IV for patency (flush with 10 mL saline and check for a blood return) because: - ANSWER The nurse knew the IV was patent because she was able to draw blood from it for labs. Intravenous Penicillin has been prescribed for a patient admitted to the hospital for treatment of pneumonia. Prior to administering the first dose of penicillin, the nurse should ask the patient: - ANSWER "Have you had a previous allergy to Penicillin?" As people become elderly in the United States, they struggle between: - ANSWER independence and safety A person just given a terminal diagnosis typically has what kind of response? - ANSWER All or any of the above One of your co-worker friends reveals to you that she has recently been having nightmares about her patients dying despite her efforts to help them. You have noticed that she has been extremely irritable, looks exhausted, and has made some inappropriate patient-care decisions. You will do which of the following to help her: - ANSWER Make arrangements for you both to go hiking together at least weekly The son of a dying patient starts yelling in a loud voice at the nursing staff about the poor quality of care the patient has received. You take the son to a quiet room to discuss his concerns. The son immediately starts crying, and apologizes for the outburst. You know the son's behavior is due to: - ANSWER Oscillation between stages of grief. A terminally ill patients states to the nurse "I can't do this anymore". What is the nurse's best response? - ANSWER "Please tell me more about what you can no longer do." Moral distress among nurses is associated with all of the following EXCEPT: - ANSWER Realizing that nurses maintain power in bedside decision making. What is the difference between standard medical care and hospice care? - ANSWER Medical care focuses on extending life at the expense of quality. Hospice helps people have the best quality of life possible, potentially at the expense of longevity. "Comfort Measures" in a patient with a DNR status is: - ANSWER Doing only the things that provide comfort and avoiding all of the things that cause discomfort Which symptoms seen in a nurse would NOT suggest compassion fatigue? - ANSWER Extremely high tolerance for frustration. According to Gawande, what is most important to people with serious illnesses? - ANSWER Not being a burden on others Avoiding suffering Being mentally aware Achieving a sense that their life is complete Strengthening relationships with friends and family A high-pressure alarm on a patient's mechanical ventilator is alarming. Which of the following actions should the nurse take LAST? - ANSWER Assess CO2 levels from ABG results The nurse is explaining the purpose of a tracheostomy tube for mechanical ventilation. Which patient statement indicated the need for additional teaching? "The tracheostomy tube is: - ANSWER Helpful in allowing the respiratory muscles to be strengthened by increasing resistance to airflow." A patient at risk for ARDS has become cyanotic and diaphoretic. Which is the nurse's priority assessment? - ANSWER Measuring pulse oximetry Which assessment finding requires the nurse's immediate action? - ANSWER The tape securing the endotracheal tube is wet with perspiration and saliva, and is no longer sticky Of the following assessment findings, which would indicate a patient is NOT ready to be weaned off mechanical ventilation? - ANSWER Unstable hemodynamics Your patient is an 18 year-old intubated female who is recovering from the flu. You are doing your initial assessment, and are now checking her ventilator settings. She is on an SIMV mode with a set rate of 16 breaths/min, and a set tidal volume of 400mL. You notice that the patient is actually breathing 18 breaths/min, with a tidal volume of 200 - 400mL. You understand that the patient is getting which of the following? - ANSWER 16 mandatory breaths at a tidal volume of 400mL, and 2 of her self-triggered breaths at a volume of 200mL. On admission, the patient's arterial blood gas (ABG) values were: pH, 7.20; PaO2, 64 mm Hg; PaCO2, 60 mm Hg; and HCO3-, 22 mEq/L. A chest tube is inserted, and oxygen at 4 L/minute is started. Thirty minutes later, his repeat blood gas values are: pH, 7.30; PaO2, 76 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 22 mEq/L. This change would indicate - ANSWER Improving respiratory status Which is the nurse's priority action for a patient suspected of experiencing a pulmonary embolism? - ANSWER Apply oxygen by mask or nasal cannula at 5 L/min A patient with acute respiratory distress syndrome (ARDS) is on a ventilator. The patient's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider with the recommendation for: - ANSWER Initiating IV sedation. What will the nurse expect to assess in a patient with respiratory failure and hypoxemia? - ANSWER agitation, disorientation, lethargy, chest pain A hi-frequency oscillating ventilator would benefit an ARDS patient because: - ANSWER both a and b Which patient would the nurse identify as benefiting from the use of noninvasive ventilation such as CPAP? - ANSWER A 57-year-old male with a history of sleep apnea Outcome criteria for evaluating the effectiveness of airway suctioning should include which of the following? - ANSWER Breath sounds clear on auscultation. Which setting on a ventilator would require a nursing intervention to improve the outcome for a 60 kg patient with acute lung injury? - ANSWER Tidal volume (Vt) = 1500 mL. Which of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated patients? - ANSWER Auscultating breath sounds bilaterally. A patient with severe respiratory insufficiency becomes severely short of breath during activities of daily living. Which nursing intervention is best? - ANSWER Space out interventions to provide for periods of rest A patient with acute lung injury is being started on enteral nutrition. Which intervention will the nurse AVOID while providing nutritional support for this patient? - ANSWER Ensure the tube feeding continues uninterrupted In caring for a brain-injured patient with damage to the cortex, which changes in respiratory and ventilatory efforts would the nurse expect to observe? - ANSWER Decreased voluntary initiation of ventilatory effort. The patient is a 106-pound woman who is being mechanically ventilated after surgery. The ventilator is volume-controlled and set at 500mL tidal volume and 16 breaths per minute. Her latest ABGs are: pH, 7.51; PaCO2, 28 mm Hg HCO3-, 23mEq/L; PaO2, 98mm Hg. What changes should be made to better accommodate the patient? - ANSWER decrease the tidal volume to 450 ml A patient is scheduled to have a surgical procedure that will require endotracheal intubation and mechanical ventilation for several days postoperatively. What will the nurse tell the patient about postoperative communication? - ANSWER "We will use a variety of strategies to make sure that your needs are met." Which statement made by a new graduate nurse about invasive mechanical ventilation techniques is incorrect and requires additional teaching? - ANSWER Assist control mode refers to the patient receiving a set tidal volume and a self-initiated volume." A nurse obtaining mixed venous gasses (SVO2) on a patient in a recent motor vehicle accident where he sustained severe crush injuries to his legs, would expect which finding? - ANSWER 95% Arterial blood gas (ABG) results of an intubated, mechanically ventilated patient are: pH = 7.33 PaO2 = 50, PaCO2 = 49 Bicarbonate = 27. The nurse would anticipate the priority action would be to: - ANSWER increased resp rate and FiO2 Hemodynamically, PEEP causes a decrease in: - ANSWER Blood pressure What will the nurse assess in a patient experiencing the fibrotic phase of acute lung injury? - ANSWER Long-term ventilator dependence. Which set of arterial blood gases will the nurse expect to find in a patient who developed a pulmonary embolism 15 minutes ago? - ANSWER pH 7.47; HCO3, 23mEq/L; PCO2, 25 mmHg; PO2, 82 mmHg A patient with hypoxia has 3 L/min nasal cannula applied. If the hypoxia does not resolve with the 3 L/min nasal cannula, what is the nurse's next action? - ANSWER Increase Nasal cannula to 5L/min A patient with ARDS has PEEP added to the mechanical ventilation therapy. Which assessment finding indicates that the use of PEEP has been effective? - ANSWER A PO2 of 92 mmHg The nurse is reviewing the health history of a patient diagnosed with an acute lung injury for a cause of the disease process. Which statement correctly identifies the cause for this type of lung injury? - ANSWER Acute lung injury can be caused indirectly from sepsis, traumas, or pancreatitis. T/F: The pulmonary edema associated with ARDS is a result of left ventricular failure - ANSWER False The nurse notes that each time the mechanical ventilator delivers a breath to a patient with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm (high pressure alarm) sounds. The nurse correlates this with a decrease in which parameter? - ANSWER Lung Compliance Your patient, SedEntary, had major abdominal surgery 3 days ago. She has had a significant amount of pain, and has been unwilling to walk around, or even get up into a chair. Ms. Entary has smoked 2 ppd for the past 10 years (and had a stroke last year), but even bribing her with cigarettes has not helped get her up and moving. She has been willing to take her daily oral contraceptive pills, however. Her husband has been at her bedside, and has been rubbing Ms. Entary's legs to help soothe her pain. 15 minutes ago, the husband came running out of the room yelling "she can't breathe, she can't breathe! She breathing as fast as a train, but she can't breathe!" You immediately go in to assess Ms. Entary, and expect which of the following results? - ANSWER Sa o2 is % What is the most important intervention for a patient with ARDS - ANSWER Oxygen therapy When planning care for a patient who is mechanically ventilated, the nurse will include interventions to address all of the following potential complications EXCEPT: - ANSWER Community Acquired Pneumonia (CAP) The nurse instructs a patient on the advantages of noninvasive mechanical ventilation. Which patient statement reflects a need for additional teaching? - ANSWER "Noninvasive ventilation is not uncomfortable and I won't have to be admitted to the ICU to use it." Which finding indicates that suctioning is required for the patient who is being mechanically ventilated? - ANSWER Wheezes and rhonchi are auscultated Your patient, SedEntary, had major abdominal surgery 3 days ago. She has had a significant amount of pain, and has been unwilling to walk around, or even get up into a chair. Ms. Entary has smoked 2 ppd for the past 10 years (and had a stroke last year), but even bribing her with cigarettes has not helped get her up and moving. She has been willing to take her daily oral contraceptive pills, however. Her husband has been at her bedside, and has been rubbing Ms. Entary's legs to help soothe her pain. The surgeon finally comes in to see Ms. Entary and orders Alteplase to treat her pulmonary embolism. You politely remind the surgeon that: - ANSWER That the patient has had major abdominal surgery and a history of a stroke, so the Alteplace is contraindicated for her. The nurse receives the following ABG result: pH = 7.00 PaCO2 = 50 mmHg PaO2 = 89 mmHg SaO2 = 90% Based on the available results, what would the nurse expect to do first? - ANSWER assess lung sounds and vital signs During multidisciplinary rounds, a discussion is held regarding the use of medications in acute respiratory distress syndrome (ARDS). Which statement is most accurate based upon published research findings? - ANSWER Inhaled nitrous oxide promotes blood flow to ventilated areas of the lungs. After suctioning a patient's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent: - ANSWER Depriving the patient of sufficient oxygen supply The nurse recognizes that utilizing the prone position to enhance oxygenation in a patient with acute respiratory distress syndrome: - ANSWER helps match ventilation with perfusion Which assessment findings would indicate to the nurse that a patient was experiencing respiratory distress? - ANSWER Tachycardia Intercostal muscle retractions. Use of abdominal muscles A patient with ARDS is on a mechanical ventilator and is becoming increasingly restless with a heart rate of 128, and total respiratory rate of 30. The SaO2 is 88% and the ventilator settings are: FiO2 50%; PEEP 8cm; AC 10; and a tidal volume of 700mL. There are coarse rhonchi audible in all lung fields, the patient is coughing, and the peak-pressure ventilator alarms are sounding. The appropriate nursing action would be to: - ANSWER hyperoxygenated with 100% o2 and suction the patient What is particularly important for the nurse to assess in a patient who is beginning noninvasive ventilatory support such as CPAP/BiPAP? - ANSWER Respiratory pattern, depth Bowel sounds and the presence of insufflation (air in the stomach) Status of skin of the nose Patient orientation and level of alertness A patient (P.E. Clotter) with a large pulmonary embolus has been receiving care on your floor for the last couple of days. You are getting a bedside report from the day nurse, and are told that last labs were done routinely that morning at 0400. You look in the electronic chart, and find only that the INR was 1.7. The nurse tells you that Mr. Clotter was having trouble breathing during the day, so she increased the IV heparin drip for patient comfort. No further labs were done that day. You look back in the chart, and find that yesterday's PTT at 0400 was 75s, and according to the heparin drip protocol used by your floor, the rate of heparin infusion was to remain the same. The next thing you do is: - ANSWER call lab and have them come up and draw STAT PTT Which assessment alerts the nurse to the possibility that the intrathoracic pressure in a mechanically ventilated patient is too high? - ANSWER Severe hypotension Which nursing action would best optimize overall oxygenation and ventilation in the patient with acute respiratory distress syndrome (ARDS)? - ANSWER Provide adequate rest and recovery time between procedures In providing care to a patient on a mechanical ventilator, the nurse correlates the administration of warm humidified oxygen with which rationale? - ANSWER To decrease viscosity of secretions A patient is admitted to the emergency department with the following arterial blood gas (ABG): pH 7.43 PaCO2 35 mmHg PaO2 55 mmHg HCO3- 24 mEq SaO2 85% What is your interpretation? - ANSWER Normal acid-base status with hypoxemia Which evidence based intervention would the nurse use to prevent pneumonia in the patient receiving mechanical ventilation? - ANSWER Administration of an H2 antagonist to prevent peptic ulcers Your patient, SedEntary, had major abdominal surgery 3 days ago. She has had a significant amount of pain, and has been unwilling to walk around, or even get up into a chair. Ms. Entary has smoked 2 ppd for the past 10 years (and had a stroke last year), but even bribing her with cigarettes has not helped get her up and moving. She has been willing to take her daily oral contraceptive pills, however. Her husband has been at her bedside, and has been rubbing Ms. Entary's legs to help soothe her pain. It has been 6 hours since Ms. Entary developed her pulmonary embolism. You would expect her blood gasses to be which of the following now? - ANSWER pH, 7.30; HCO3-, 22 mEq/L; PCO2, 60 mm Hg; PO2, 66 mm Hg The use of PEEP (positive end expiratory pressure) in a patient with hypovolemia is likely to directly result in - ANSWER A low cardiac output state. Which statement accurately describes the purpose of sedation vacation for a patient to prevent ventilator-associated pneumonia? - ANSWER The patient's own tidal volume and respiratory rate can be evaluated during sedation vacation A patient with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived (see below). Which finding should the nurse report to the health care provider? pH: 7.35 PaCO2: 25mmHg HCO3-: 22 mEq/L PaO2: 95mmHg - ANSWER PaCO2 Your patient, SedEntary, had major abdominal surgery 3 days ago. She has had a significant amount of pain, and has been unwilling to walk around, or even get up into a chair. Ms. Entary has smoked 2 ppd for the past 10 years (and had a stroke last year), but even bribing her with cigarettes has not helped get her up and moving. She has been willing to take her daily oral contraceptive pills, however. Her husband has been at her bedside, and has been rubbing Ms. Entary's legs to help soothe her pain. 15 minutes ago, the husband came running out of the room yelling " she can't breathe, she can't breathe! She breathing as fast as a train, but she can't breathe!" The next thing that must be done for Ms. Entary is: - ANSWER Apply oxygen by nasal cannula or mask at 5 L/min The nurse is caring for a patient with acute respiratory distress syndrome who is being mechanically ventilated. What actions will the nurse take to prevent ventilator-induced injury? - ANSWER Keep the peak inspiratory pressure limit set to prevent barotrauma A nurse is suctioning an intubated, mechanically ventilated patient. Immediate complications that should be observed for include - ANSWER Dysrhythmias A 27 year-old chemistry student is on your floor because a beaker of concentrated hydrochloric acid exploded this morning in the lab and immediately became a noxious gas. You become concerned with which of the following findings? - ANSWER SaO2 88% despite 3 L/min oxygen per nasal cannula A nurse is caring for a patient who was intubated because of respiratory failure. The patient is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The patient has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: - ANSWER synchronized intermittent mandatory ventilation (SIMV) In a recently extubated patient exhibiting stridor, which is the nurse's best action after applying humidified oxygen - ANSWER Notify the emergency response team A patient is intubated due to decreasing ability to maintain oxygenation and ventilation. Which of the following would be expected immediately after intubation? - ANSWER A drop in blood pressure A patient with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived (see below). Which finding should the nurse report to the health care provider? pH: 7.35, PaCO2: 25mmHg, HCO3-: 22 mEq/L, PaO2: 95mmHg - ANSWER PaCO2 A patient admitted with shortness of breath demonstrates the following findings: temperature 36.8 C, HR 120/min sinus tachycardia, BP 130/76 mmHg, RR 36/min with SpO2 91%. Breath sounds reveal inspiratory crackles in all lung fields. The chest x-ray report states that there is enlargement of the peribronchial hilar spaces, and enlarged cardiac silhouette. These findings are consistent with which of the following? - ANSWER : Pulmonary edema The patient being mechanically ventilated has become more restless over the course of the shift. Which is the nurse's best action? - ANSWER Checks the patient's oxygen saturation by pulse oximetry DVT bundle includes: - ANSWER 1. HOB 30 degrees 2. Daily sedation vacation 3. Peptic ulcer prevention 4. DVT prevention 5. Oral care with chlorhexidine. The nurse is instructing a patient with a myocardial infarction about the disease process. Which patient statement indicates that additional teaching is needed? - ANSWER "Angina always leads to decreased blood flow to the heart muscle and then tissue death." The nurse is assessing a patient for heart failure. Which early findings would indicate decreased cardiac output and a potential for fluid overload from heart failure? - ANSWER Orthopnea, peripheral edema, crackles A patient says, "I've never heard of an acute coronary syndrome. Please explain what happened to me." The nurse should respond, "Acute coronary syndrome is: - ANSWER A group of disorders that result in insufficient oxygen supply to the heart." A patient brought to the emergency room has been diagnosed with an acute myocardial infarction and is ordered thrombolytic therapy with Reteplase. The nurse correlates which rationale with the administration of this medication - ANSWER Restoring perfusion to the injured area, reducing the size of the infarct A nurse is monitoring a patient undergoing exercise electrocardiography (stress test). Which assessment finding necessitates that the test be stopped? - ANSWER The patient's electrocardiogram (ECG) indicates significant ST segment depression Which of the following actions has the highest priority for maintaining safety when caring for a patient with a PA catheter? - ANSWER Maintain asepsis when providing line care A patient with a right subclavian triple lumen catheter has a CVP reading of 18 mmHg. The nurse would further assess the patient for symptoms of: - ANSWER peripheral edema with jugular vein distention After an inferior-septal wall myocardial infarction, which complication should a nurse suspect when noting jugular venous distention (JVD) and ascites? - ANSWER right sided heart failure Which patient response indicates that the patient has had a favorable response to Atropine? - ANSWER An increase in heart rate to 80 bpm A patient has mixed venous oxygen saturation (SVO2) of 42% with the following hemodynamic findings: CO of 4.8 L/min, SaO2 of 95%, and an unchanged hemoglobin level. The nurse should assess the patient for: - ANSWER pain A nurse is caring for a patient who has just started to bleed from the insertion site following a cardiac catheterization. What should be the nurse's first response? The nurse should - ANSWER apply manual pressure to the site A patient undergoes emergency CABG surgery after failed thrombolysis and a percutaneous coronary intervention (PCI) in which coronary artery dissection occurred. Prior to surgery, the patient was alert and able to give verbal consent. Mediastinal and pleural chest tubes are present with moderate drainage. Moderate oozing is also present at the sternotomy and saphenous vein graft incisions and at the right groin sheath site. The patient has a PA catheter, an NG tube, and a urinary catheter in place. Frequent assessments by the nurse for this patient should include which of the following? - ANSWER Hourly groin palpation and neurovascular checks of the leg used for PCI A patient has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected? - ANSWER Decreased cardiac output Which assessment finding indicates that a patient's heart failure is worsening? - ANSWER The onset of atrial fibrillation The nurse wants to assess the oxygenation status of a patient who has been experiencing a gastrointestinal bleed. How will the nurse complete this assessment? - ANSWER Check the pulse oximetry and send a blood sample for arterial blood gas analysis What should the nurse prepare to administer to a patient with sustained supraventricular tachycardia (SVT)? - ANSWER Adenosine A nurse is preparing to administer the first 5 mg dose of Metoprolol to a patient who is 12 hours post MI. For which assessment finding should the nurse withhold administration of the medication? - ANSWER Sinus brady 49 bpm A 67-year-old male patient complaining of "feeling tired" has the following cardiac rhythm. The patient states that he has a history of an irregular heartbeat. His vital signs are BP 134/78; RR 17; SaO2 97% on room air. He denies other complaints at present. The priority action for this patient would be to: - ANSWER perform a 12 lead ekg and compare to previous ekgs What action would be most helpful to the nurse in determining whether the chest pain of a patient who has just entered the emergency department is cardiac in origin? - ANSWER perform a 12 lead ekg A patient is admitted with chest discomfort and a possible myocardial infarction. What would be a contraindication to administration of fibrinolytic medications to the patient? The patient had - ANSWER A stroke within the past month A patient comes in to the ER with chest pain. A nurse reviews the following lab results (normal values in parentheses): CPK (0-160u/L): 320 CK-MB (0-16u/L): 32 Troponin T (0.0-0.4ng/mL): 34 WBC (3.9-11.9 K/mcL): 14 Hgb (13.1-17.1 %): 15 Hct (38.7-51 g/dL): 48 What does the nurse need to do first? - ANSWER Prepare patient to go immediately to cardiac catheterization When a patient says, "The chest pain occurs each time I play basketball; it does not occur when I am sleeping; and it improves when I take those pills under my tongue," the pain will most likely be classified as: - ANSWER Stable angina A patient with heart failure has a decreasing cardiac output. The nurse will expect compensatory mechanisms to be activated in order to: - ANSWER Maintain perfusion to vital organs The nurse planning care for a patient recovering from a cardiac angiogram with stent placement will anticipate all of the following interventions EXCEPT - ANSWER Administer blood products for low blood pressure A nurse obtains a pulmonary artery pressure reading of 25/12 mmHg in a patient recovering from a myocardial infarction. Which is the nurse's first intervention based on these findings? - ANSWER Compares the results with previous readings A patient is very short of breath. Which finding should cause the nurse to be concerned that the shortness of breath might be due to heart failure? - ANSWER A BNP (B-type natriuretic peptide) of 300 pg/mL A patient with a PA (Swan) catheter has an SVO2 of 90%. The nurse should assess the patient for: - ANSWER Hypothermia When teaching a class of new nursing graduates, the nurse would expect the students to describe atrial fibrillation on an EKG strip as having: - ANSWER No consistent P waves, only an erratic and wavy baseline between normally configured QRS waves. Which finding would support the diagnosis of heart failure? - ANSWER PCWP of 20mmhg Following cardiac reperfusion treatments, a patient develops the following: hematuria, hypotension, tachycardia, a drop in hemoglobin and hematocrit, and a decrease in oxygen saturation. What is most likely the cause for these symptoms? - ANSWER Over-anticoagulation A patient with sepsis is in the ICU, and has a PA catheter. The mixed venous oxygen saturation (SvO2) is 86%. The patient's SaO2 is 92%, and temperature is 96.2 F. Which is the nurse's primary intervention? - ANSWER Apply warm blankets to the patient because they are not extracting enough oxygen at the tissue level to avoid anaerobic metabolism and subsequent acidemia. The nurse is caring for the patient with acute pain associated with a myocardial infarction (MI). What is the goal or purpose of collaborative management for this patient? - ANSWER Eliminate discomfort by providing pain relief modalities, decrease myocardial oxygen demand, and increase myocardial oxygen supply. A patient is experiencing chest pain, shortness of breath, and lethargy. The patient's vital signs are BP 88/58, HR 40, RR 20. Which nursing action is a priority for this patient? - ANSWER Atropine 1 mg IVP. What should the nurse monitor in response to a change in SVO2 readings? - ANSWER hemoglobin levels Atrial fibrillation is characterized by all the following EXCEPT: - ANSWER Saw-tooth or picket fence P waves Which of the following will the nurse NOT include in the plan of care for a patient with atrial fibrillation? - ANSWER Prepare the patient for unsynchronized defibrillation to assist in controlling heart rate. The nurse is instructing a patient with a myocardial infarction about the disease process. Which patient statement indicates that additional teaching is needed? - ANSWER Angina always leads to decreased blood flow to the heart muscle and then tissue death." What action is appropriate for the nurse to implement when monitoring the EKG of a patient with a transvenous temporary pacemaker? The EKG strip shows QRS complexes without pacer spikes. - ANSWER Assess the patient and continue to observe the EKG rhythm What is the PRIORITY assessment for a patient experiencing atrial fibrillation with a rapid ventricular response? - ANSWER Assessing for shortness of breath An 80-year-old woman has arrived in the emergency department. The health care provider is questioning whether she has had an MI although she is not displaying the classic chest pain. Which symptoms would more likely occur in this patient than others because of the patient's gender and age? - ANSWER Generalized fatigue accompanied by dyspnea and diaphoresis At 0730 hours, a nurse receives a verbal order for a cardiac catheterization to be completed on a patient at 1400 hours. Which action should the nurse initiate first - ANSWER Initiate NPO (nothing per mouth) status for the patient A nurse is caring for a patient with a temporary ventricular pacemaker. The patient's bedside monitor shows a spike followed by a QRS complex. Which would be the nurse's best action? - ANSWER Document the finding as the only action What is the most appropriate position for a patient in pulmonary edema with a blood pressure of 194/92? - ANSWER Sitting upright with legs dependent A patient's heart disease has resulted in a reduction of stroke volume. Which compensatory mechanism is expected? - ANSWER Increased heart rate A patient tells a nurse, "My chest pain starts when I am resting, and when I had a cardiac catheterization, the doctor said I was having vasospasms." Which type of medication would the nurse anticipate to be prescribed to treat the patient's angina? - ANSWER A calcium channel blocking agent Microvascular disease: SELECT ALL THAT APPLY. - ANSWER -Affects the nervous system -Is worsened by high blood pressure -Is worsened by high glucose levels -Occurs in the eyes -Occurs in the kidneys -Is worsened by high cholesterol levels -Occurs in the heart A patient has returned from an angiography via the left femoral artery. Two hours after the procedure the nurse notes that the left pedal pulse is weak. What is the nurse's priority action? - ANSWER Assess the color and temperature of the leg. A nurse is assessing a patient diagnosed with an anterior-lateral myocardial infarction (MI). The nurse adds a nursing diagnosis to the patient's plan of care of decreased cardiac output when which finding is noted on assessment? - ANSWER Crackles auscultated in bilateral lung bases A patient's systemic vascular resistance (SVR) has dangerously decreased. The nurse would expect to administer which medications? - ANSWER A vasoconstrictor such as Dopamine Nursing interventions for the patient with sinus tachycardia include which of the following? - ANSWER Remove or treat the underlying cause, such as fever, pain, or anxiety. A patient recently diagnosed with a right inferior wall MI, now has a BNP (brain natriuretic peptide) level of 20,000 pg/mL, and has been receiving intravenous Furosemide as the only treatment. Which of the following hemodynamic parameters would suggest that the current treatment is not relieving the symptoms of congestive heart failure? - ANSWER CVP reading of 18 with a PCWP of 22 The health care provider is planning to insert a PA (Swan) catheter into a patient. The nurse realizes this monitoring device is used for all of the following EXCEPT: - ANSWER Continuously monitoring the blood pressure After receiving a total of three Nitroglycerin sublingual tablets, a patient admitted to the hospital with complaints of chest pain states there is no change in the level of discomfort. What will the nurse do next? - ANSWER Notify the health care provider. A patient is very short of breath. Which finding should cause the nurse to be concerned that the shortness of breath might be due to heart failure? - ANSWER A BNP (B-type natriuretic peptide) of 300 pg/mL The nurse is taking the history of a patient with suspected CAD who has had episodes of chest discomfort while mowing the lawn. Because the chest discomfort subsides when the patient rests, the nurse correlates this with which condition? - ANSWER Stable angina The patient in pulseless ventricular tachycardia is defibrillated twice and received appropriate medications per ACLS protocol. The following rhythm is now present. What should the nurse do next? - ANSWER Check the patient for a pulse and continue CPR if one is not present The multidisciplinary team would identify all of the following goals for initial collaborative management of a patient with an acute myocardial infarction EXCEPT? - ANSWER Strengthen the heart by increasing activity as soon as possible The electrocardiog