Clinical Assessment
A patient with pneumonia has an RR of 28, SpO₂ of 89%, and increasing work of breathing. Which finding is the most concerning?
A. Temperature 100.8°F
B. Productive cough
C. SpO₂ 89% with increased work of breathing
D. Fatigue
C.- Patient is de-saturating. ABC'S! :)
A client with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The client is admitted to the cardiac critical care unit after the PTCA. What priority complication should the nurse monitor for?
A. Bleeding at the insertion site
B.Left Ventricular Hypertrophy
C. Transient Angina
A. Bleeding at the insertion site
Rationale: Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery.
Identify the anticoagulation medication that may be prescribed for CAD patients?
A. Digoxin
B. Metoprolol
C. Apixaban
D. Hydralazine
C. Apixaban
What causes Sinus Tachycardia?
(List 3)
Temp
Aerobic activity
Cardiac disease
Hyperthyroidism
Yelp! (pain)
Hemorrhage
Emotional stress
Anemia
Respiratory
Therapeutics (meds)
Stimulants
Which finding is commonly associated with fluid overload in a patient with heart failure?
A. Dry mucous membranes
B. Crackles in the lungs
C. Decreased blood pressure only
D. Increased bowel sounds
B.
Rationale: Crackles in the lungs indicates fluid overload.
A patient with heart failure has gained 4 lb in 2 days and has bilateral crackles. What complication should the nurse suspect?
Fluid volume overload/pulmonary congestion
A client with coronary artery disease (CAD) is having a cardiac catheterization. What indicator is present for the client to have a coronary artery bypass graft (CABG)?
A. The patient has had angina for more than 3 years
B. They have an ejection fraction of 55%
C. At least 70% occlusion of a major coronary artery
C. At least 70% occlusion of a major coronary artery
Rationale:For a client to be considered for CABG, the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if in the left main coronary artery).
Which Beta Blocker is most commonly prescribed for CAD patients?
A. Metoprolol
B. Nitroglycerine
C. Amlodipine
B. Metoprolol (-olol's) are classified as Beta Blockers.
What are 3 signs/symptoms a patient MIGHT have if they have a cardiac arrythmia?
Palpitation
Chest pain
SOB
Feeling of doom
Diaphoresis
Pallor
Which medication is a loop diuretic commonly used to decrease fluid overload in patients with heart failure?
A. Furosemide
B. Metoprolol
C. Lisinopril
D. Atorvastatin
A. Furosemide
A patient suddenly becomes confused. Which finding would be most important to assess first?
A. Last BM
B. Oxygen saturation
C.Labs
D. Sleep pattern
The nurse is explaining the cause of angina pain to a client. What will the nurse say most directly caused the pain?
A. Artery blockage/closure.
B. Lack of oxygen to the heart muscle cells
C. Death of heart tissue
B. Lack of oxygen to the heart muscle cells
Rationale: Angina pectoris refers to chest pain that is brought about by myocardial ischemia.
The nurse is providing education to a patient that is taking Clopidogrel (Plavix). What would the nurse include in the teaching? (Select all that apply)
A. Use a soft-bristled toothbrush and an electric razor to prevent cuts.
B. Seek emergency medical care immediately if you hit your head or experience a hard fall, even if you feel fine
C.Avoid NSAIDs like ibuprofen or naproxen, and products containing aspirin.
A,B,C- these are all teachings for a patient on antiplatelet drugs- as they are at an increased risk for bleeding.
How does a Premature Ventricular Contraction (PVC) present on an EKG strip?
A. Normal P wave, Normal QRS wave & Normal T wave
B. No P-wave, Broad QRS- greater than 0.12, T-wave- opposite to deflection
C. No P wave, No QRS , and irregular T wave.
B. No P wave, Broad QRS T wave opposite of QRS.
Which patient should the nurse assess first?
A. Heart failure patient with 1+ ankle edema
B. Heart failure patient who gained 2 lb since yesterday
C. Heart failure patient with new severe shortness of breath and crackles
D. Heart failure patient asking about their low-sodium diet
C. Heart Failure patient with new severe shortness of breath and crackles.
A patient reports severe abdominal pain. Their abdomen is rigid and distended. What should the nurse first?
Perform an immediate focused assessment and notify the nurse/provider promptly because rigidity and distention can indicate an obstruction/perforation of the bowels.
A patient receiving warfarin (Coumadin) is being discharged. Which statement by the patient indicates a need for further teaching?
A. “I’ll have my INR checked regularly.”
B. “I’ll use an electric razor to reduce my risk of bleeding.”
C. “I can take aspirin whenever I have a headache.”
D. “I’ll report unusual bruising or bleeding to my provider.”
C.
Aspirin can increase the risk of bleeding when taken with warfarin. Patients should avoid aspirin and other NSAIDs unless specifically instructed by their provider
A patient is taking Nitroglycerin at home for onset of chest pain. How does the patient correctly take this medication?
1 tab under tongue- every 5 minutes for no more than 3 total doses.
Your patient goes into Asystole, put the options below in order of priority:
A. Call Code Blue
B. Assess your patient
C. Start CPR
D. Administer EPI
B,A,C,D.
Rationale: We always assess the patient before calling code blue- are the leads on? Is the patient awake and alert? Code blue asap, CPR and then EPI.
What are 4 PRIORITY things you would monitor in a patient with heart failure? (Select all that apply)
A. Blood pressure
B.I&O's
C. Daily Weight
D. Blood glucose
A,B,C
D- not a priority.
Rationale: Blood glucose can be monitored in some patients, especially if they have diabetes or are taking certain medications, but it doesn’t directly tell us how the heart failure or fluid status is changing.
A patient with COPD is increasingly lethargic and confused. RR 10, SpO₂ 84%, and they are difficult to arouse. What should the nurse do next?
Focused Resp assessment-Assess airway and breathing immediately, sit them up and call RRT.
Which term refers to preinfarction angina?
A. Unstable Angina
B. Silent Angina
C. Stable Angina
A. Unstable Angina
Which medications can be used to treat or prevent symptoms of angina in a patient with CAD? Select all that apply
A. Nitroglycerin
B. Beta blockers
C. Calcium channel blockers
D. Ranolazine
E. Aspirin
Rationale:
What are 4 EKG findings for a patient with A-fib? (select all that apply)
A. Atrial rate is 300-400
B. Irregular rhythm
C. No identifiable P wave
D. Normal QRS duration
E. Normal P-R interval
A,B,C,D.
E: Not correct because we have many p-waves, its not possible to accurately measure a P-R interval.
A patient with a history of heart failure suddenly develops:
What complication should the nurse suspect, and what is the priority?
Acute pulmonary edema related to worsening heart failure.
The priority is immediate ABC assessment and intervention for respiratory compromise, including calling for assistance.