low activity level the patient reports.
When developing a health teaching plan for a 65-year-old patient with all these risk factors for coronary artery disease (CAD), the nurse will focus on the __________
Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible.
To assist the patient with CAD to make the appropriate dietary changes, which of these nursing interventions will be most effective?
The pain has persisted longer than 30 minutes.
The nurse is admitting a patient who is complaining of chest pain to the emergency department (ED). Which information collected by the nurse suggests that the pain is caused by an acute myocardial infarction (AMI)?
visualize any coronary artery blockages and dilate any obstructed arteries.
A patient is admitted to the ED after an episode of severe chest pain, and the physician schedules the patient for coronary angiography and possible percutaneous coronary intervention (PCI). The nurse prepares the patient for the procedure by explaining that it is used to ________________________
The patient indicates that the pain is resolved after taking one sublingual nitroglycerin tablet.
Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?
Which electrocardiographic (ECG) change will be of most concern to the nurse when admitting a patient with chest pain?
Chest pain level 8 on a 10-point scale
When caring for a patient with ACS who has returned to the coronary care unit after having a PCI, the nurse obtains these assessment data. Which data indicate the need for immediate intervention by the nurse?
identifying the need to call the emergency medical services (EMS) if chest pain persists 5 minutes after taking nitroglycerin.
In developing a teaching plan for a patient who has stable angina and is started on sublingual nitroglycerin (Nitrostat), the nurse identifies an expected patient outcome of
"I will miss being able to eat peanut butter sandwiches."
Which of these statements made by a patient after the nurse has completed teaching about the TLC diet indicates that further teaching is needed?
"It is important not to suddenly stop taking the atenolol."
After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective?
A patient who has had severe chest pain for the last 4 hours is admitted with a diagnosis of possible AMI. Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an MI?
decrease spasm of the coronary arteries.
Nifedipine (Procardia) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that Procardia will ____________
the cardiac monitor shows a heart rate of 45.
A patient with chronic stable angina is being treated with metoprolol (Lopressor). The nurse will suspect that the patient is experiencing a side effect of the metoprolol if __________________
ability to do daily activities without chest discomfort.
Nadolol (Corgard) is prescribed for a patient with angina. In evaluating the effectiveness of the drug, the nurse will monitor for _________________
acute pain related to myocardial ischemia.
A patient admitted to the coronary care unit (CCU) with an MI and frequent premature ventricular contractions (PVCs) has health care provider orders for continuous amiodarone infusion, IV nitroglycerin infusion, and morphine sulfate 2 mg IV every 10 minutes until there is relief of pain. The patient says, "This is the worst pain I have ever had. Am I going to die?" Based on these data, the nurse identifies a priority nursing diagnosis of ___________________
Heparin will prevent the development of clots in the coronary arteries.
A patient with a non-ST segment elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin?
Attach the cardiac monitor.
While admitting a patient with an AMI, which action should the nurse carry out first?
relief of chest discomfort.
The nurse administers IV nitroglycerin to a patient with an MI. In evaluating the effect of this intervention, the nurse should monitor for _______________
"What time did your chest pain begin?"
A patient with ST-segment elevation in several ECG leads is admitted to the ED and diagnosed as having an AMI. Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy?
Heart rate increases from 66 to 90 beats/min.
Following an AMI, a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response, which of these assessment data would indicate that the exercise level should be decreased?
a decrease in level of consciousness.
During the administration of the fibrinolytic agent to a patient with an AMI, the nurse should stop the drug infusion if the patient experiences _______________
No change in the patient's chest pain
A patient is receiving fibrinolytic therapy 2 hours after developing an AMI. Which assessment information will be of most concern to the nurse?
pericardial friction rub.
Three days after an MI, the patient develops chest pain that radiates to the back and left arm and is relieved by sitting in a forward position. On auscultation of the patient's chest, the nurse would expect to hear a ____________
"I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."
After the nurse teaches a patient with chronic stable angina about how to use the prescribed nitrates, which statement by the patient indicates that the teaching has been effective?
situational low self-esteem related to perceived role changes.
Two days after having an MI, a patient tells the nurse, "I wish I had died when I had this heart attack. I won't be able to do anything now." The most appropriate nursing diagnosis is ___________________
The lungs have crackles audible to the midline.
The nurse obtains the following data when caring for a patient who experienced an AMI 2 days previously. Which information is most important to report to the health care provider?
about the purpose of outpatient Holter monitoring.
When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an AMI, the nurse will anticipate teaching the patient _______________
Allow the use of denial as a coping mechanism until the patient begins asking questions about the MI.
A few days after experiencing an MI, the patient states, "I just had a little chest pain. As soon as I get out of here, I'm going for my vacation as planned." Which nursing intervention is appropriate to include in the nursing care plan?
"I will have incisions in my leg where they will remove the vein."
When evaluating the outcomes of preoperative teaching with a patient scheduled for a coronary artery bypass graft (CABG) using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says, ________________
"Sexual activity can be gradually resumed like other activity. A good comparison of energy expenditure is climbing two flights of stairs."
After having an AMI, a 62-year-old patient tells the nurse, "I guess having sex again will be too hard on my heart." The nurse's best response is ______________
Administration of the ordered metoprolol (Lopressor) and aspirin
Which of these nursing interventions included in the plan of care for a patient who had an AMI 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN?
Generalized muscle aches and pains
A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports all the following symptoms to the nurse. Which is most important to communicate to the health care provider?
A patient who has chest pain is admitted to the ED, and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first?
when patient cardiac rehabilitation will begin.
For a patient who has been admitted the previous day to the coronary care unit with an AMI, the nurse will anticipate teaching the patient about _______________
Give the patient's other medications 2 hours after the Welchol.
A patient with hyperlipidemia has a new order for the bile-acid sequestrant medication colesevelam (Welchol). Which nursing action is appropriate when giving the medication?
A patient who is being admitted to the emergency department with severe chest pain gives the following list of medications taken at home to the nurse. Which of the medications has the most immediate implications for the patient's care?
A 51-year-old who has just returned to the unit after a coronary arteriogram and PCI
The nurse has just received change-of-shift report about these four patients. Which patient should the nurse assess first?
auscultate the lung sounds.
A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to ________________
assess the patient for clinical manifestations of acute heart failure because an exacerbation of the chronic heart failure may be occurring.
A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about a 5-pound weight gain in the last 3 days. The nurse's first action will be to _______________
elevated right atrial pressure.
During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates _____________
decreased dyspnea with the head of the bed at 30 degrees.
The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is ____________________
hypertension eventually will lead to heart failure by overworking the heart muscle.
When the nurse is developing a teaching plan to prevent the development of heart failure in a patient with stage 1 hypertension, the information that is most likely to improve compliance with antihypertensive therapy is that _______________
administer IV morphine sulfate 2 mg.
A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to _______________
a systolic BP <90 mm Hg.
Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the Nipride rate if the patient develops ____________
paroxysmal nocturnal dyspnea.
A patient admitted to the hospital with an exacerbation of chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse can best document this assessment information as _______________
impaired skin integrity related to peripheral edema.
During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best nursing diagnosis for the patient is _________________
calls when the weight increases from 124 to 130 pounds in a week.
The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient ________________
positioning the patient in a high-Fowler's position with the feet horizontal in the bed.
When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such as ______________
milk, yogurt, and other milk products.
When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include ________________
notify the health care provider immediately if nausea or difficulty breathing occurs.
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin), hydrochlorothiazide (HydroDIURIL), and a potassium supplement. Appropriate instructions for the patient include _______________
an oxygen saturation of 88% on room air.
The nurse identifies the collaborative problem of potential complication: pulmonary edema for a patient in ADHF. When assessing the patient, the nurse will be most concerned about ______________
referral to a home health care agency.
While admitting an 80-year-old patient with heart failure to the medical unit, the nurse obtains the information that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." The nurse makes a note that discharge planning for the patient will need to include _____________
serum potassium level is 3.0 mEq/L after 1 week of therapy.
A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control of heart failure. The patient data that will require the most immediate action by the nurse is if the patient's _________________
angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).
Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about _______________
candidacy for heart transplant depends on many factors.
A 55-year-old patient with inoperable coronary artery disease and end-stage heart failure asks the nurse whether heart transplant is a possible therapy. The nurse's response to the patient will be based on the knowledge that ____________
has BP of 88/42.
An outpatient who has developed heart failure after having an acute myocardial infarction has a new prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic. The assessment finding that will be of most concern to the nurse is that the patient ______________
B-type natriuretic peptide (BNP).
An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is ______________
dilate arterial and venous blood vessels, decreasing ventricular preload and afterload.
A patient with ADHF who is receiving nesiritide (Natrecor) asks the nurse how the medication will work to help improve the symptoms of dyspnea and orthopnea. The nurse's reply will be based on the information that nesiritide will ___________
Monitor the patient's BP every hour.
A patient who is receiving dobutamine (Dobutrex) for the treatment of ADHF has all of the following nursing actions included in the plan of care. Which action will be best for the RN to delegate to an experienced LPN/LVN?
"I will call for help when I need to get up to the bathroom."
A hospitalized patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about captopril, which statement by the patient indicates that teaching has been effective?
In analyzing a patient's electrocardiographic (ECG) rhythm strip, the nurse uses the knowledge that the time of the conduction of an impulse through the Purkinje fibers is represented by the __________________
use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.
When needing to estimate the ventricular rate quickly for a patient with a regular heart rhythm using an ECG strip, the nurse will ______________
A patient has a junctional escape rhythm on the monitor. The nurse would expect the patient to have a pulse rate of ____ beats/min.
Obtain further information about possible causes for the heart rate.
A patient who is complaining of a "racing" heart and nervousness comes to the emergency department. The patient's blood pressure (BP) is 102/68. The nurse places the patient on a cardiac monitor and obtains the following ECG tracing.
Which action should the nurse take next?
A patient has a dysrhythmia that requires careful monitoring of atrial activity. Which lead will be best to use for continuous monitoring?
The nurse obtains a monitor strip on a patient admitted to the coronary care unit with a myocardial infarction and makes the following analysis: P wave not apparent; ventricular rate 162, R-R interval regular; PR interval not measurable; and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as _______________
every other QRS complex is wide and starts prematurely.
The nurse determines that a patient has ventricular bigeminy when the rhythm strip indicates that ________________
document the finding and continue to monitor the patient.
A patient has a normal cardiac rhythm strip except that the PR interval is 0.34 seconds. The appropriate intervention by the nurse is to ________________
A patient with diabetes mellitus is admitted unresponsive to the emergency department (ED). Initial laboratory findings are serum potassium 2.8 mEq/L (2.8 mmol/L), serum sodium 138 mEq/L (138 mmol/L), serum chloride 90 mEq/L (90 mmol/L), and blood glucose 628 mg/dl (34.9 mmol/L). Cardiac monitoring shows multifocal PVCs. The nurse understands that the patient's PVCs are most likely caused by _______________
administer IV antidysrhythmic drugs per protocol.
The nurse reviews data from the cardiac monitor indicating that a patient with a myocardial infarction experienced a 50-second episode of ventricular tachycardia before a sinus rhythm and a heart rate of 98 were re-established. The most appropriate initial action by the nurse is to ________________
third-degree AV block.
A patient experiences dizziness and shortness of breath for several days. During cardiac monitoring in the ED, the nurse obtains the following ECG tracing.
The nurse interprets this cardiac rhythm as _______________
increase in the patient's heart rate.
A patient with myocardial infarction develops symptomatic hypotension. The monitor shows a type 1, second-degree AV block with a heart rate of 30. The nurse administers IV atropine as prescribed. The nurse determines that the drug has been effective on finding a(n) _________________
anticoagulant therapy with warfarin (Coumadin).
A patient with dilated cardiomyopathy has an atrial fibrillation that has been unresponsive to drug therapy for several days. The nurse anticipates that further treatment of the patient will require ____________
start basic cardiopulmonary resuscitation (CPR).
The nurse hears the cardiac monitor alarm and notes that the patient has a cardiac pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious with no pulse or respirations. After calling for assistance, the nurse should _______________
apical radial heart rate.
During change-of-shift report, the nurse learns that a patient with a large myocardial infarction has been having frequent PVCs. When monitoring the patient for the effects of PVCs, the nurse will check the patient's _____________
"You had a serious abnormal heart rhythm, which treatment was able to reverse."
A patient who has been successfully resuscitated after developing ventricular fibrillation asks the nurse about what happened. The most appropriate response by the nurse is, _____________
stimulate a heart beat if the patient's own heart rate drops too low.
17. A patient has a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response. The nurse teaches the patient that the pacemaker will ____________
"I won't lift the arm on the pacemaker side up very high until I see the doctor."
A patient has received instruction on the management of a new permanent pacemaker before discharge from the hospital. The nurse recognizes that teaching has been effective when the patient tells the nurse, _______________
if the ICD fires and the patient loses consciousness, 911 should be called.
A patient who has a history of sudden cardiac death has an ICD inserted. When performing discharge teaching with the patient, it is important for the nurse to instruct the patient and family that ______________
administer a sedative before the procedure is begun.
A patient with supraventricular tachycardia (SVT) is hemodynamically stable and requires cardioversion. The nurse will plan to _______________
Hold the ordered metoprolol (Lopressor) and call the health care provider.
A patient's sinus rhythm rate is 62. The PR interval is 0.18 seconds at 1:00 AM, 0.20 seconds at 12:30 PM, and 0.23 seconds at 4:00 PM. Which action should the nurse take?
Obtain and apply the transcutaneous pacemaker (TCP).
A patient develops sinus bradycardia at a rate of 32 beats/min, has a BP of 80/36 mm Hg, and is complaining of feeling faint. Which action should the nurse take?
Question the patient about current stress level and coffee use.
A 21-year-old college student arrives at the student health center at the end of the quarter complaining, "My heart is skipping beats." The nurse obtains an ECG and notes the presence of occasional PVCs. What action should the nurse take first?
Allow the student to participate on the swim team.
A 19-year-old student has a mandatory ECG before participating on a college swim team and is found to have sinus bradycardia, rate 52. BP is 114/54, and the student denies any health problems. What action by the nurse is appropriate?
A patient whose ICD fired three times today who is scheduled for a dose of amiodarone (Cordarone)
The nurse has received change-of-shift report about all of these patients on the telemetry unit. Which patient should the nurse see first?
QRS interval of 0.14 second.
When analyzing the waveforms of a patient's ECG, the nurse will need to investigate further upon finding a _________
When analyzing an ECG rhythm strip of a patient with a regular cardiac rhythm, the nurse finds there are 25 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ______.
1 Turn the defibrillator on.
2 Select the appropriate energy level
3 Place the paddles on the patient's chest.
4 Check the location of other personnel and call out "all clear."
5 Deliver the electrical charge.
When a patient requires defibrillation, in which order will the nurse accomplish the following steps?
"Have you been to the dentist lately?"
The nurse obtains a health history from a patient with a prosthetic mitral valve who has symptoms of infective endocarditis. Which question by the nurse is most appropriate?
obtaining the blood cultures.
The health care provider writes the following admitting orders for a patient with suspected IE who has fever and chills: ceftriaxone (Rocephin) 1.0 g intravenous piggyback (IVPB) q12hr, acetylsalicylic acid (ASA) for temperature above 102° F (38.9° C), and blood cultures ∗ 2, complete blood cell count (CBC), and electrocardiogram (ECG). When admitting the patient, the nurse gives the highest priority to ____________
dyspnea and a dry, hacking cough.
During the assessment of a patient with IE, the nurse would expect to find _________
urine output less than 30 ml/hr.
The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with IE based on the assessment finding of _____________
the patient will be able to receive outpatient IV antibiotic therapy if complications such as heart failure do not develop.
A patient hospitalized with a streptococcal infective endocarditis tells the nurse," I know that I need antibiotics, but I do not want to be hospitalized for very long." The nurse explains that
A patient hospitalized with IE develops sharp left flank pain and hematuria. The nurse notifies the health care provider, recognizing that these symptoms may indicate ______________
A patient is admitted to the hospital with possible acute pericarditis. The nurse will plan to teach the patient about the purpose of ______________
place the diaphragm of the stethoscope at the lower left sternal border of the chest.
To assess the patient with pericarditis for the presence of a pericardial friction rub, the nurse should _____________
Jugular vein distension (JVD) to the level of the jaw
Which of these assessment data obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider?
note when Korotkoff sounds are audible during both inspiration and expiration.
Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should _____________
position the patient in Fowler's position, leaning forward on the overbed table.
The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The most appropriate intervention by the nurse for this problem is to ______________
"Have you had a recent sore throat?"
While obtaining an admission health history from a patient with possible rheumatic fever, which question will be most pertinent to ask?
activity intolerance related to fatigue and arthralgia.
A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. An appropriate nursing diagnosis based on these findings is ______________
"I will be immune to further episodes of rheumatic fever after this infection."
The nurse establishes the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge concerning long-term management of rheumatic fever when a patient recovering from rheumatic fever says, _______________
teaching people to seek medical diagnosis and treatment for streptococcal pharyngitis.
The community health nurse involved in programs to prevent rheumatic fever knows that the most important intervention to decrease the incidence of the disease is ________________
The patient complains of chest pain associated with ambulation.
Which assessment information obtained by the nurse for a patient with aortic stenosis would be most important to report to the health care provider?
dyspnea and hemoptysis.
When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for ______________
long-term anticoagulation is necessary after mechanical valve replacement.
A 21-year-old woman is scheduled for an open mitral valve commissurotomy for treatment of mitral stenosis. When explaining the advantage of valve repair instead of valve replacement to the patient, the nurse will include the information that _____________
discuss the diagnosis of mitral valve prolapse with the dentist.
While caring for a patient with mitral valve prolapse with mild valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient tells the nurse she will _______________
promote rest to decrease myocardial oxygen demand.
While caring for a patient with aortic stenosis, the nurse establishes a nursing diagnosis of pain related to decreased coronary blood flow. An appropriate intervention by the nurse is to ___________
how to monitor anticoagulation therapy.
During postoperative teaching with a patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient regarding ______________
Auscultate the heart sounds.
A few days after an acute MI, a patient complains of stabbing chest pain that increases with deep breathing. Which action will the nurse take first?
Oral ibuprofen (Motrin) 800 mg
A patient who has had recent cardiac surgery develops pericarditis and complains of severe chest pain with deep breathing. Which of these ordered PRN medications should the nurse administer?
The patient has crackles audible to the lung apices.
Which information obtained by the nurse when assessing a patient admitted with mitral valve stenosis should be communicated to the health care provider immediately?
When caring for the patient with infective endocarditis of the tricuspid valve, the nurse will plan to monitor the patient for ____________
Notify the doctor about any symptoms of heart failure such as shortness of breath.
A patient who has developed acute pulmonary edema is hospitalized and diagnosed with dilated cardiomyopathy. Which information will the nurse plan to include when teaching the patient about management of this disorder?
The patient's 29-year-old brother has had a sudden cardiac arrest.
The nurse is taking a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC); which information obtained by the nurse is most relevant?
"Heparin will help prevent blood clots from forming in your heart chambers."
Heparin is prescribed for a patient who has dilated cardiomyopathy has been admitted to the hospital with fatigue and orthopnea. Which statement is appropriate for the nurse to use in patient teaching about anticoagulation therapy?
A patient with a history of a 4-cm abdominal aortic aneurysm is admitted to the emergency department with severe back pain and bilateral flank ecchymoses. The vital signs are blood pressure (BP) 90/58, pulse 138, and respirations 34. The nurse plans interventions for the patient based on the expectation that treatment will include ____________
atherosclerotic plaques damage the artery and may lead to aneurysms.
A 69-year old patient is admitted to the hospital for elective repair of an abdominal aortic aneurysm. The history includes hypertension for 25 years, hyperlipidemia for 15 years, and smoking for 50 years. The patient asks the nurse what caused the aneurysm. The nurse's best response includes the information that ______________
A patient has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining a nursing history from the patient, the nurse will ask the patient about _________
blood urea nitrogen (BUN) and creatinine.
Several hours following a surgical repair of an abdominal aortic aneurysm, the patient develops left flank pain and a urinary output of 20 ml/hr for 2 hours. The nurse notifies the health care provider and anticipates orders for a(n)
administer IV fluids at a rate to keep the arterial BP within a normal range.
The nurse identifies a nursing diagnosis of risk for altered peripheral tissue perfusion related to bypass graft thrombosis for a patient following an abdominal aneurysm repair. An appropriate intervention to prevent this problem in the immediate postoperative period is to _______________
Review the preoperative assessment form for data about the pulses.
After repair of an abdominal aortic aneurysm, the nurse notes that the patient does not have popliteal, posterior tibial, or dorsalis pedis pulses. The legs are cool and mottled. Which action is appropriate for the nurse to take first?
titrate oxygen to keep O2 saturation greater than 90%.
A nursing action that is indicated for the collaborative problem of potential complication: cardiac dysrhythmia in a patient who has had a repair of a descending thoracic aortic aneurysm is to
passing of flatus with ambulation.
When the nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, the information that is most significant when the nurse is assessing for the return of peristalsis is ______________
the use of antihypertensive medications to lower the risk of further dissection or bleeding.
A 72-year-old patient is hospitalized for an aortic dissection of the abdominal aorta that stabilizes with treatment. The nurse develops a teaching plan for the patient's discharge that includes information about _______________
keep the patient in bed in the supine position.
A patient recovering on a general surgical unit from an aortic valve replacement 1 week ago develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the health care provider and _______________
attempt to palpate the dorsalis pedis and posterial tibial pulses.
During an assessment of a 63-year-old patient at the clinic, the patient says, "I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." The nurse should _____________
prolonged capillary refill.
The nurse performing an assessment with a patient who has chronic peripheral arterial disease (PAD) of the legs would expect to find _______________
"I will use a heating pad on my feet at night to increase the circulation and warmth in my feet."
The nurse identifies the nursing diagnosis of ineffective peripheral perfusion related to decreased arterial blood flow for a patient with chronic PAD. In evaluating the patient outcomes following patient teaching, the nurse determines a need for further instruction when the patient says, ______________
The LPN/LVN has the patient sit in a bedside chair for 90 minutes.
A patient who has had a femoral-popliteal bypass graft to the right leg is being cared for on the surgical unit. Which action by an LPN/LVN caring for the patient requires the RN to intervene?
Cessation of smoking
A 36-year-old patient who has a history of thromboangiitis obliterans (Buerger's disease) is admitted to the hospital with a gangrenous lesion of the right small toe. When the nurse is planning expected outcomes for the patient, which outcome has the highest priority for this patient?
The patient exercises indoors during the winter months.
After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which behavior by the patient indicates that the teaching has been effective?
put one pillow under the thighs and two pillows under the lower legs.
A patient admitted to the hospital with DVT has health care provider's orders for bed rest with the feet elevated. The best method for the nurse to use in elevating the patient's feet is to _____________
avoid any IM medications to prevent localized bleeding.
The health care provider orders a continuous IV heparin infusion for a patient with swelling and pain of the upper leg caused by a DVT. While the patient is receiving the heparin infusion, the nurse should _____________
Maintain bed rest as ordered.
The nurse has identified the collaborative problem of potential complication: pulmonary embolism for a patient with left-calf DVT. Which nursing action is appropriate to include in the plan of care?
"The heparin will work immediately, but the Coumadin takes several days to have an effect on coagulation."
A patient with a DVT is started on IV heparin and oral warfarin (Coumadin). The patient asks the nurse why two medications are necessary. The nurse's best response to the patient is, __________
"I should change my diet to include more green, leafy vegetables."
The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for DVT. The nurse determines that additional teaching is needed when the patient says, _________________
compression stockings should be applied before getting out of bed.
A 42-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Before discharging the patient, the nurse teaches the patient that ___________
application of external compression to the lower leg.
In planning care for a patient with a venous stasis ulcer on the right lower leg, the nurse understands that the most important intervention in promoting healing of the ulcer is
"I can't get my shoes on at the end of the day."
A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of these statements by the patient is most consistent with the diagnosis?
Assist the patient in using a pillow to splint while coughing.
Which of these nursing actions in the care plan for a patient who had a repair of an abdominal aortic aneurysm 5 days previously is most appropriate for the nurse to delegate to an experienced nursing assistant?
"I will tell my dentist about this surgery the next time I have an appointment."
Which statement by a patient who is being discharged 5 days after an abdominal aortic aneurysm repair and graft indicates that the discharge teaching has been effective?
"Call if you notice that your stools are black or have blood in them."
A patient with PAD has a new prescription for clopidogrel (Plavix). Which information should the nurse include when teaching the patient about this medication?
A patient who is seen in the clinic tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud's phenomenon. The nurse will anticipate teaching the patient about tests for ______________
"My legs cramp whenever I walk more than a block."
While working in the outpatient clinic, the nurse notes that the chart states that a patient has intermittent claudication. Which of these statements by the patient would be consistent with this information?
"It is important to try to stop smoking."
When developing a teaching plan for a patient newly diagnosed with PAD, which information should the nurse include?
0.78 or 0.79
When assessing a patient with possible PAD, the nurse obtains a brachial BP of 140/80 and an ankle pressure of 110/70. The nurse calculates the patient's ankle-brachial index (ABI) as ______.