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Final Fall 2022 - Med Surgical
Terms in this set (189)
The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease.
Which information will be
most
important for the nurse to includeOptions for smoking cessationA patient with newly diagnosed lung cancer tells the nurse, I don't think I'm going to live to see my next birthday. Which response by the nurse is best?Can you tell me what it is that makes you think you will die so soonAn hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next?Set up the patient controlled analgesia (PCA) and administer the loading dose of morphineThe nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?400 mL of blood in the collection chamberA patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial
assessment?Paradoxic chest movementWhen assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?Insertion of a chest tube with a chest drainage systemA patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-
control chamber of the collection device. Which action by the nurse is most appropriate?Take no further action with the collection deviceA patient is admitted to the emergency department with an open stab wound to the left chest. What is the
first action that the nurse should take?Tape a nonporous dressing on three sides over the chest woundThe nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?Document the amount of drainage every eight hoursAfter change-of-shift report, which patient should the nurse assess first?64-year-old with lung cancer and tracheal deviation after subclavian catheter insertionThe nurse teaches a patient with chronic bronchitis about a new prescription for Advair Diskus (combined fluticasone and salmeterol). Which action by the patient would indicate to the nurse that teaching about medication administration has been successful?The patient rapidly inhales the medicationThe nurse teaches a patient how to administer formoterol (Perforomist) through a nebulizer. Which action by the patient indicates good understanding of the teaching?The patient removes the facial mask when misting has ceased.A patient is scheduled for pulmonary function testing. Which action should the nurse take to prepare the patient for this procedure?Withhold bronchodilators for 6 to 12 hours before the examination.Which information will the nurse include in the asthma teaching plan for a patient being dischargedTremors are an expected side effect of rapidly acting bronchodilators.A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). It is most appropriate for the nurse to teach the patient about?a 1-antitrypsin testingThe nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which information obtained from the patient would prompt the nurse to consult with the health care provider before administering the prescribed theophylline?The patient takes cimetidine (Tagamet) 150 mg dailyA patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most
appropriate to include in the plan of care?Teach the patient how to effectively use pursed lip breathingA patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include
in the plan of care?Offer high-calorie snacks between meals and at bedtimeThe nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed?The patient puffs up the cheeks while exhalingWhich finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment?Pulse oximetry reading of 92%The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding?Peripheral edemaThe nurse is admitting a patient diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD).What is the
best way for the nurse to determine the appropriate oxygen flow rate?Maintain the pulse oximetry level at 90% or greaterPostural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care?Give the ordered albuterol (Proventil) before the patient receives the therapyA patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, I wish I were dead! I'm just a burden on everybody. Based on this information, which nursing diagnosis is most appropriateChronic low self-esteem related to increased physical dependenceA patient with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would be most
appropriate?Encourage the patient to sit up at the bedside in a chair and lean slightly forwardA 55-year-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary function testing (PFT) for this condition, what is the most important question the nurse should ask?Have you taken any bronchodilators in the past 6 hours?A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?Perform chest physiotherapy every 4 hoursA young adult female patient with cystic fibrosis (CF) tells the nurse that she is not sure about getting married and having children some day. Which initial
response by the nurse is best?Do you need any information to help you with that decision?A patient with chronic obstructive pulmonary disease (COPD) has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be
most effective?The nurse provides dietary teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effectiveI can have ice cream as a snack every dayA patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implementTeach the patient about administration of insulinThe nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse?22-year-old with ABG results: pH 7.28, PaCO2- 60 mm Hg, and PaO2 - 58 mm HgThe nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first?A patient with a respiratory rate of 38/minuteWhich finding in a patient hospitalized with bronchiectasis is
most important to report to the health care
provider?Cough productive of bloody, purulent mucusEKGHeart Rate - 60-100
PR Interval - 0.12-0.20 seconds - Atrial Depolarization and contraction of atrium
QRS Interval - <0.12 seconds - Ventricle Depolarization or contraction of ventricles (systole)
ST Segment Interval - 0.12 seconds - Time between ventricle depolarization and repolarization
QT Interval - 0.34-0.43 seconds - time taken for entire ventricular depolarization and repolarization of the ventriclesWhile assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patients bed elevated 45 degrees. The nurse knows this finding indicate?increased right atrial pressureThe nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of
acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator
that the treatment has been effective?Reduced dyspnea with the head of bed at 30 degreeWhich topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%?Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitorIV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develop?a systolic BP <90 mm HgA patient who has chronic heart failure tells the nurse, I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating! The nurse will document this assessment finding of?Paroxysmal nocturnal dyspneaDuring a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle
edema, a 2-kg weight gain over the past 2 days, and complains of feeling too tired to get out of bed. Based on these data, the
best nursing diagnosis for the patient isActivity intolerance related to fatigueThe nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that?She will call the clinic if her weight goes from 124 to 128 pounds in a weekWhen teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include?Milk, yogurt, and other milk products.The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient includeNotify the health care provider if nausea developsWhile admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that
the patient lives alone and sometimes confuses the water pill with the heart pill. When planning for the patients discharge the nurse will facilitate aReferral to a home health care agencyFollowing an acute myocardial infarction, a previously healthy 63-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about?angiotensin-converting enzyme (ACE) inhibitorsWhich diagnostic test will be
most useful to the nurse in determining whether a patient admitted with acute
shortness of breath has heart failure?B-type natriuretic peptideWhich action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)?Monitor blood pressure frequentlyA 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 the drug, which statement by the patient indicates that teaching has
been effective?I will call for help when I need to get up to use the bathroom.A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving?Carvedilol (Coreg) 3.125 mgA patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse do first?Auscultate the breath soundsA patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurses priority action will be to?Assess the patient for clinical manifestations of acute heart failure.
THE WEIGHT gain is a manifestation of heart failureAfter receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first?A patient who is cool and clammy, with new-onset confusion and restlessnessWhich assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse?Oxygen saturation of 88%A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider?Serum potassium level 3.0 mEq/L after 1 week of therapy.
NORMAL RANGE 3.5-4.5An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider?Blood pressure (BP) of 88/42 mm HgA patient who is receiving dobutamine (Dobutrex) for the treatment of acute decompensated heart failure
(ADHF) has the following nursing interventions included in the plan of care. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?Monitor the patients blood pressure and heart rate every hour.After receiving change-of-shift report on a heart failure unit, which patient should the nurse assess first?Patient who is taking digoxin and has a potassium level of 3.1The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate?Have you had dental work done recently?During the assessment of a 25-year-old patient with infective endocarditis (IE), the nurse would expect to find?a new regurgitant murmurThe nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)Urine output less than 30 mL/hWhen planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is a priority for the nurse to include?Arrange for placement of a long-term IV catheter.A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of?echocardiographyTo assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should?Auscultate by placing the diaphragm of the stethoscope on the lower left sternal borderThe nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should?Note when Korotkoff sounds are auscultated during both inspiration and expirationThe nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history will be most pertinent to ask?Have you had a recent sore throat?A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest
pain with deep breathing. Which ordered PRN medication will be the most appropriate for the nurse to giveOral ibuprofen (Motrin) 600 mgThe nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge regarding long-term management of rheumatic fever when a 30-year-old recovering from rheumatic fever
without carditis says which of the following?I will be immune to further episodes of rheumatic fever after this infectionWhen developing a community health program to decrease the incidence of rheumatic fever, which action would be most important for the community health nurse to includeTeach community members to seek treatment for streptococcal pharyngitis.When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of?Shortness of breathThe nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for which patient?Patient who had a mitral valve replacement with a mechanical valveWhich admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement?Order blood cultures drawn from two sitesWhich assessment finding in a patient who is admitted with infective endocarditis (IE) is
most important to communicate to the health care provider?Sudden onset right flank painWhich assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider?Jugular venous distention (JVD) to jaw levelTwo days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first?Auscultate the heart soundsWhich action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are effective?Assess for the presence of jugular venous distention (JVD)The nurse is assessing a patient with myocarditis before administering the scheduled dose of digoxin (Lanoxin). Which finding is
most important for the nurse to communicate to the health care provider?Irregular pulseWhen discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factorUncontrolled hypertensionA patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about?Trouble swallowingSeveral hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n)blood urea nitrogen (BUN) level.A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of medications will the nurse plan to include when providing patient teaching about PAD management?StatinsThe nurse is caring for a patient with a descending aortic dissection. Which assessment finding is
most important to report to the health care providerBlood pressure 137/88 mm HgWhich nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?Help the patient to use a pillow to splint while coughingWhen caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is
most important for the nurse to communicate to the health care provider?Loose, bloody stoolsThe nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first?Notify the surgeon and anesthesiologistAfter receiving report, which patient admitted to the emergency department should the nurse assess first?50-year-old who is complaining of sudden sharp and worst ever upper back painAn 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take
first?Obtain the blood pressureA 46-year-old female patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take?Obtain a midstream urine specimen for culture and sensitivity testingThe nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-year-old female patient with cystitis when the patient states which of the following?I will empty my bladder every 3 to 4 hours during the dayWhich information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine (Pyridium)Pyridium may change the urine colorWhich finding by the nurse will be
most helpful in determining whether a 67-year-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)Costovertebral tendernessThe nurse determines that further instruction is needed for a patient with interstitial cystitis when the patient says which of the following?I will start taking high potency multiple vitamins every morningWhen planning teaching for a 59-year-old male patient with benign nephrosclerosis the nurse should include instructions regardingmonitoring and recording blood pressureThe nurse will plan to teach a 27-year-old female who smokes 2 packs of cigarettes daily about the increased risk forbladder cancerA 68-year-old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care?Assist the patient to the bathroom every 2 hours during the dayA patient who had surgery for creation of an ileal conduit 3 days ago will not look at the stoma and requests that only the ostomy nurse specialist does the stoma care. The nurse identifies a nursing diagnosisdisturbed body image related to change in functionWhich information from a patient who had a transurethral resection with fulguration for bladder cancer 3 days ago is most
important to report to the health care providerThe patient has seen clots in the urineWhen preparing a female patient with bladder cancer for intravesical chemotherapy, the nurse will teach
aboutemptying the bladder before the medicationNursing staff on a hospital unit are reviewing rates of hospital-acquired infections (HAI) of the urinary tract. Which nursing action will be
most helpful in decreasing the risk for HAI in patients admitted to the
hospital?Avoiding unnecessary urinary catheterizationWhich assessment finding for a patient who has just been admitted with acute pyelonephritis is
most important for the nurse to report to the health care provider?Blood pressure 90/48 mm HgA 58-year-old male patient who is diagnosed with nephrotic syndrome has ascites and 4+ leg edema. Which nursing diagnosis is a
priority for the patient?Excess fluid volume related to low serum protein levelA 76-year-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first?Insert a urinary retention catheterWhich nursing action is of highest
priority for a 68-year-old patient with renal calculi who is being admitted to the hospital with gross hematuria and severe colicky left flank painAdminister prescribed analgesicsA 58-year-old male patient who weighs 242 lb (110 kg) undergoes a nephrectomy for massive kidney trauma due to a motor vehicle crash. Which postoperative assessment finding is
most important to communicate to the surgeon?Urine output is 20 mL/hr for 2 hoursA 22-year-old female patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most
important for the nurse to report to the health care providerLeft-sided flank painWhich action will the nurse anticipate taking for an otherwise healthy 50-year-old who has just been diagnosed with Stage 1 renal cell carcinoma?Provide preoperative teaching about nephrectomyWhen a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of?rapid, deep respirationsThe nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will bemaintaining cardiac output.A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV?Cardiac rhythmA 48-year-old patient with stage 2 chronic kidney disease (CKD) is scheduled for an intravenous pyelogram
(IVP). Which order for the patient will the nurse question?Ibuprofen (Advil) 400 mg PO PRN for painWhich statement by a 62-year-old patient with stage 5 chronic kidney disease (CKD) indicates that the nurses teaching about management of CKD has been effectiveI will measure my urinary output each day to help calculate the amount I can drinkWhich information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?Phosphate levelSodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess thebowel soundsWhich menu choice by the patient who is receiving hemodialysis indicates that the nurses teaching has been successful?Poached eggs, whole-wheat toast, and apple juiceBefore administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the
nurse should check laboratory results forserum phosphateA 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be
most useful to the nurse in evaluating improvement in kidney functionGlomerular filtration rate (GFR)The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required?Magnesium hydroxideBefore administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patientspotassiumA patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patientserum creatineWhich intervention will be included in the plan of care for a male patient with acute kidney injury (AKI) who has a temporary vascular access catheter in the left femoral veinRestrict physical activity to bed rest.A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be
most important to report to the health care providerSerum potassium level 6.5 mEq/LA 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by
dehydration. Which information will be
most important for the nurse to report to the health care providerUrine output over an 8-hour period is 2500 mlA patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first?Check the medical record for most recent potassium levelA 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first?Place the patient on a cardiac monitorA licensed practical/vocational nurse (LPN/LVN) is caring for a patient with stage 2 chronic kidney disease. Which observation by the RN requires an intervention?The LPN/LVN administers the iron supplement and phosphate binder with lunchA 74-year-old who is progressing to stage 5 chronic kidney disease asks the nurse, Do you think I should go on dialysis? Which initial response by the nurse is best?Tell me more about what you are thinking regarding dialysisWhen developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery
disease (CAD), the nurse should focus on theelevation of the patients low-density lipoprotein (LDL) levelWhich nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changesHelp the patient modify favorite high-fat recipes by using monosaturated oils when possibleWhich assessment data collected by the nurse who is admitting a patient with chest pain suggest that the pain is caused by an acute myocardial infarction (AMI)The pain has lasted longer than 30 minutesWhich information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?The patient states that the pain goes away with one sublingual nitroglycerin tabletAfter the nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective?I will call an ambulance if I still have pain after taking 3 nitroglycerin 5 minutes apartWhich statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed?I will miss being able to eat peanut butter sandwichesAfter the nurse teaches the patient about the use of carvedilol (Coreg) in preventing anginal episodes, which
statement by a patient indicates that the teaching has been effectiveIt is important not to suddenly stop taking the carvedilolA patient who has had chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test should the nurse monitor to help determine whether the patient has had
an AMI?Cardiac-specific troponinDiltiazem (Cardizem) is ordered for a patient with newly diagnosed Prinzmetals (variant) angina. When teaching the patient, the nurse will include the information that diltiazem wdecrease spasm of the coronary arteriesThe nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if theblood pressure is 90/54 mm HgNadolol (Corgard) is prescribed for a patient with chronic stable angina and left ventricular dysfunction. To determine whether the drug is effective, the nurse will monitor forthe ability to do daily activities without chest painHeparin is ordered for a patient with a nonST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparinHeparin prevents the development of new clots in the coronary arteriesWhen titrating IV nitroglycerin (Tridil) for a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication?Ask about chest painA patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to
the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction
(STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic
therapy?What time did your chest pain begin?Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the
nurse is evaluating the patients response to the activity, which assessment data would indicate that the exercise
level should be decreasedHeart rate increases from 66 to 92 beats/minuteDuring the administration of the thrombolytic agent to a patient with an acute myocardial infarction (AMI),
the nurse should stop the drug infusion if the patient experiencea decrease in level of consciousnessA patient is recovering from a myocardial infarction (MI) and develops chest pain on day 3 that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next?Auscultate for a pericardial friction rub.In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been
effective?I will stop what I am doing and sit down before I put the nitroglycerin under my tongueThree days after experiencing a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with hygiene activities, saying, I am too nervous to take care of myself. Based on this information, which nursing diagnosis is appropriate?Ineffective coping related to anxietyA few days after experiencing a myocardial infarction (MI) and successful percutaneous coronary intervention, the patient states, I just had a little chest pain. As soon as I get out of here, Im going for my
vacation as planned. Which reply would be
most appropriate for the nurse to make?What do you think caused your chest pain?When evaluating the effectiveness of preoperative teaching with a patient scheduled for coronary artery
bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says which of the following?I will have small incisions in my leg where they will remove the veinA patient who is recovering from an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best?Sexual activity uses about as much energy as climbing two flights of stairsA patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is most appropriate when giving the medication?Make sure to give other medications 2 hours after the WelcholThe nurse is caring for a patient who was admitted to the coronary care unit following an acute myocardial infarction (AMI) and percutaneous coronary intervention the previous day. Teaching for this patient would includewhen cardiac rehabilitation will beginA patient who has recently started taking pravastatin (Pravachol) and niacin (Nicobid) reports the following
symptoms to the nurse. Which is
most important to communicate to the health care provider?Generalized muscle aches and painWhich assessment finding by the nurse caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the health care provider?Pallor and weakness of the right handA patient with diabetes mellitus and chronic stable angina has a new order for captopril (Capoten). The nurse should teach the patient that the primary purpose of captopril is toprevent changes in the heart muscleWhich patient at the cardiovascular clinic requires the most immediate action by the nurse?Patient with stable angina whose chest pain has recently increased in frequencyAfter receiving change-of-shift report about the following four patients, which patient should the nurse assess first?59-year-old with unstable angina who has just returned to the unit after having a percutaneous
coronary intervention (PCI)A patient who has chest pain is admitted to the emergency department (ED) and all of the following are ordered. Which one should the nurse arrange to be completed first?Electrocardiogram (ECG)A patient had a nonST-segment-elevation myocardial infarction (NSTEMI) 3 days ago. Which nursing intervention included in the plan of care is most appropriate for the registered nurse (RN) to delegate to an
experienced licensed practical/vocational nurse (LPN/LVN)Reinforcement of teaching about the purpose of prescribed medicationThe nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is
most important to report to the health
care provider?Bilateral crackles are auscultated in the mid-lower lobesWhich information about a patient who has been receiving thrombolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care providerNo change in the patients chest pain
MAY INDICATE THAT A PCI IS NEEDEDWhen admitting a patient with a nonST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first?Attach the cardiac monitor.When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having angioplasty with stent placement, the nurse obtains the following assessment data. Which data indicate
the need for immediate action by the nurse?Chest pain level 7 on a 0 to 10 point scaleWhich electrocardiographic (ECG) change is
most important for the nurse to report to the health care provider when caring for a patient with chest pain?ST- Segment ElevationTo assess for functional deficits, which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumorAre you experiencing visual problems?Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?Encourage the use of effective insect repellents during mosquito seasonA patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse
question?Restrict oral fluids to 1000 mL daily
WE WANT TO ENCOURAGE FLUIDSA patient being admitted with bacterial meningitis has a temperature of 102.5 F (39.2 C) and a severe headache. Which order for collaborative intervention should the nurse implement first?Swab the nasopharyngeal mucosa for cultures
WE NEED TO SWAB FIRSTA patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unitCheck capillary blood glucose level every 6 hoursThe charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to interveneThe staff nurse suctions the patient routinely every 2 hours
SHOULD ONLY BE DONE AS NEEDEDWhen assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care providerThe patients blood pressure is 88/42 mm HgA patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?Unlicensed assistive personnel enter the patients room without a mask
SPREAD BY RESPIRATORY SECRETIONSThe public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is
most important?Immunize adolescents and college freshman against
Neisseria meningitidesA 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?Encourage family members to remain at the bedsideAfter having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is toperform range-of-motion (ROM) exercises every 4 hoursThe nurse admitting a patient who has a right frontal lobe tumor would expect the patient may haveimpaired judgmentA 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?Keep the head of the bed elevated to 30 degreesWhich nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with sclerodermaDocument the patients oral intakeAfter the nurse assesses a 78-year-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management, which information is most important to report to the health care providerLaboratory results indicate blood urea nitrogen (BUN) is elevatedWhich information will the nurse include when teaching a patient with newly diagnosed chronic fatigue syndrome about self-managementA gradual increase in your daily exercise may help decrease fatigueWhich patient seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)?A 56-year-old woman who works on an automotive assembly line
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