Moana
A nurse assesses a patient after administering a prescribed beta-blocker. Which assessment would the nurse expect to find?
a. Blood pressure increased from 98/42 to 132/60 mm Hg
b. Respiratory rate decreased from 25 to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 to 80 beats/min
ANS: D
Beta-blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta-blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.
PTS: 1 DIF: Cognitive Level: Applying KEY: Beta blocker | medication
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse assesses patients on a medical-surgical unit. Which patient would the nurse identify as having the greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma
b. A 32-year-old Asian-American man with colorectal cancer
c. A 45-year-old American Indian woman with diabetes mellitus
d. A 53-year-old postmenopausal woman who is on hormone therapy
ANS: C
The incidence of coronary artery disease and hypertension is higher in American-Indians than in whites or Asian-Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase the risk for cardiovascular disease.
PTS: 1 DIF: Cognitive Level: Understanding KEY: Health screening
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse assesses an older adult patient who has multiple chronic diseases. The patient’s heart rate is 48 beats/min. What action would the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the patient’s medications.
d. Administer 1 mg of atropine.
ANS: C
Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse would check the medication reconciliation for medications that might cause such a drop in heart rate, and then would inform the healthcare provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.
PTS: 1 DIF: Cognitive Level: Applying KEY: Medication | health screening
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
An emergency room nurse obtains the health history of a patient. Which statement by the patient would alert the nurse to the occurrence of heart failure?
a. “I get short of breath when I climb stairs.”
b. “I see halos floating around my head.”
c. “I have trouble remembering things.”
d. “I have lost weight over the past month.”
ANS: A
Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.
PTS: 1 DIF: Cognitive Level: Remembering KEY: Health screening | heart failure
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse cares for a patient who has advanced cardiac disease and states, “I am having trouble sleeping at night.” What is the nurse’s best response?
a. “I will consult the provider to prescribe a sleep study to determine the problem.”
b. “You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.”
c. “A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night.”
d. “Use pillows to elevate your head and chest while you are sleeping.”
ANS: D
The patient is experiencing orthopnea (shortness of breath while lying flat). The nurse would teach the patient to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this patient. Oxygen and CPAP will not help a patient with orthopnea.
PTS: 1 DIF: Cognitive Level: Understanding
KEY: Heart failure | orthopnea | patient education
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Basic Care and Comfort
A nurse is assessing patients on a medical-surgical unit. Which patient would the nurse identify as being at greatest risk for atrial fibrillation?
a. A 45-year-old who takes an aspirin daily
b. A 50-year-old who is postcoronary artery bypass graft surgery
c. A 78-year-old who had a carotid endarterectomy
d. An 80-year-old with chronic obstructive pulmonary disease
ANS: B
Atrial fibrillation occurs commonly in patients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these patients at higher risk for atrial fibrillation.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Health screening | cardiac electrical conduction
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse is assessing patients on a medical-surgical unit. Which patient would the nurse identify as being at greatest risk for atrial fibrillation?
a. A 45-year-old who takes an aspirin daily
b. A 50-year-old who is postcoronary artery bypass graft surgery
c. A 78-year-old who had a carotid endarterectomy
d. An 80-year-old with chronic obstructive pulmonary disease
ANS: B
Atrial fibrillation occurs commonly in patients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these patients at higher risk for atrial fibrillation.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Health screening | cardiac electrical conduction
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse assesses a patient with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity
ANS: B
Patients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Patients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Patients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Cardiac electrical conduction | vascular perfusion
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse evaluates prescriptions for a patient with chronic atrial fibrillation. Which medication would the nurse expect to find on this patient’s medication administration record to prevent a common complication of this condition?
a. Sotalol (Betapace)
b. Warfarin (Coumadin)
c. Atropine (Sal-Tropine)
d. Lidocaine (Xylocaine)
ANS: B
Atrial fibrillation puts patients at risk for developing emboli. Patients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Cardiac electrical conduction | medication
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A telemetry nurse assesses a patient who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment would the nurse complete next?
a. Pulmonary auscultation
b. Pulse strength and amplitude
c. Level of consciousness
d. Mobility and gait stability
ANS: C
A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The patient is at risk for inadequate cerebral perfusion. The nurse would assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the patient’s level of consciousness is the priority.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Cardiac electrical conduction | vascular perfusion
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse assesses patients on a cardiac unit. Which patient would the nurse identify as being at greatest risk for the development of left-sided heart failure?
a. A 36-year-old woman with aortic stenosis
b. A 42-year-old man with pulmonary hypertension
c. A 59-year-old woman who smokes cigarettes daily
d. A 70-year-old man who had a cerebral vascular accident
ANS: A
Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.
PTS: 1 DIF: Cognitive Level: Applying KEY: Heart failure | health screening
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse assesses a patient with mitral valve stenosis. What clinical manifestation would alert the nurse to the possibility that the patient’s stenosis has progressed?
a.
Oxygen saturation of 92%
b.
Dyspnea on exertion
c.
Muted systolic murmur
d.
Upper extremity weakness
ANS: B
Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not relate to the progression of mitral valve stenosis.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Valve disorder | respiratory distress/failure
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse is caring for a patient with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure would the nurse implement?
a. Apply an ice pack to the patient’s chest.
b. Provide a neck rub, especially on the left side.
c. Allow the patient to lie in bed with the lights down.
d. Sit the patient up with a pillow to lean forward on.
ANS: D
Pain from acute pericarditis may worsen when the patient lays supine. The nurse would position the patient in a comfortable position, which usually is upright and leaning slightly forward. Pain is decreased by using gravity to take pressure off the heart muscle. An ice pack and neck rub will not relieve this pain.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Nonpharmacologic pain management
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Basic Care and Comfort
A nurse assesses a patient who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess?
a. Preventricular contractions
b. Atrial fibrillation
c. Symptomatic bradycardia
d. Sinus tachycardia
ANS: B
Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis. Preventricular contractions and bradycardia are not associated with valvular problems. These are usually identified in patients with electrolyte imbalances, myocardial infarction, and sinus node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease in cardiac output.
PTS: 1 DIF: Cognitive Level: Understanding
KEY: Valve disorder | cardiac dysrhythmia
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene?
a. Assessing blood pressure in both upper extremities
b. Auscultating the carotid arteries for any bruits
c. Classifying capillary refill of 4 seconds as normal
d. Palpating both carotid arteries at the same time
ANS: D
The student would not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure would be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits would be auscultated.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Nursing assessment | neurologic system | neurologic assessment
MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
The nurse is reviewing the lipid panel of a male patient who has atherosclerosis. Which finding is most concerning?
a. Cholesterol: 126 mg/dL
b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL
c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL
d. Triglycerides: 198 mg/dL
ANS: D
Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males.
PTS: 1 DIF: Cognitive Level: Remembering KEY: Laboratory values | lipid alterations
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse is working with a patient who takes atorvastatin (Lipitor). The patient’s recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?
a. Ask if the patient eats grapefruit.
b. Assess the patient for dehydration.
c. Facilitate admission to the hospital.
d. Obtain a random urinalysis.
ANS: A
There is a drug–food interaction between statins and grapefruit that can lead to acute kidney failure. This patient has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse would assess if the patient eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The patient does not necessarily need to be admitted. A urinalysis may or may not be ordered.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Laboratory values | statins | nursing assessment | medication-food interaction
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A student nurse asks what “essential hypertension” is. What response by the registered nurse is best?
a. “It means it is caused by another disease.”
b. “It means it is ‘essential’ that it be treated.”
c. “It is hypertension with no specific cause.”
d. “It refers to severe and life-threatening hypertension.”
ANS: C
Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.
PTS: 1 DIF: Cognitive Level: Understanding
KEY: Hypertension | pathophysiology | patient education
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
The nurse is caring for four hypertensive patients. Which drug–laboratory value combination would the nurse report immediately to the healthcare provider?
a. Furosemide (Lasix)/potassium: 2.1 mEq/L
b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L
c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L
d. Torsemide (Demadex)/sodium: 142 mEq/L
ANS: A
Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and would be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Hypertension | antihypertensive medications | laboratory values
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse is assessing a patient with peripheral artery disease (PAD). The patient states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information?
a. “Could you walk further than that a few months ago?”
b. “Do you walk mostly uphill, downhill, or on flat surfaces?”
c. “Have you ever considered swimming instead of walking?”
d. “How much pain medication do you take each day?”
ANS: A
As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates that the patient’s disease is worsening. The other questions are useful, but not as important.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Pain | exercise | activity | peripheral vascular disease | pain assessment
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
An older patient with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the patient may indicate a barrier to proper foot care?
a. “I nearly always wear comfy sweatpants and house shoes.”
b. “I’m glad I get energy assistance so my house isn’t so cold.”
c. “My daughter makes sure I have plenty of lotion for my feet.”
d. “My hands shake when I try to do things requiring coordination.”
ANS: D
Patients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The patient whose hands shake may cause injury when trimming toenails. The nurse would refer this patient to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for patients with PVD. Keeping the house at a comfortable temperature makes it less likely the patient will use alternative heat sources, such as heating pads, to stay warm. The patient should keep the feet moist and soft with lotion.
PTS: 1 DIF: Cognitive Level: Analyzing
KEY: Peripheral vascular disease | self-care | home safety
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Health Promotion and Maintenance
A nurse is caring for four patients. Which one would the nurse see first?
a. Patient who needs a beta-blocker, and has a blood pressure of 92/58 mm Hg
b. Patient who had a first dose of captopril (Capoten) and needs to use the bathroom
c. Hypertensive patient with a blood pressure of 188/92 mm Hg
d. Patient who needs pain medication prior to a dressing change of a surgical wound
ANS: B
Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse would see this patient first to prevent falling if the patient decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse would check on the patient with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta-blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The patient who needs pain medication prior to the dressing change is not a priority over patient safety and assisting the other patient to the bathroom.
PTS: 1 DIF: Cognitive Level: Analyzing
KEY: Hypertension | angiotensin-converting enzyme (ACE) inhibitors | antihypertensive medications | patient safety MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse is caring for a patient with a deep vein thrombosis (DVT). What nursing assessment indicates that a priority outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors
ANS: B
A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.
PTS: 1 DIF: Cognitive Level: Analyzing
KEY: Pulmonary embolism | deep vein thrombosis | respiratory assessment | thromboembolic event
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse is caring for a patient with a nonhealing arterial lower leg ulcer. What action by the nurse is best?
a. Consult with the wound care nurse.
b. Give pain medication prior to dressing changes.
c. Maintain sterile technique for dressing changes.
d. Prepare the patient for eventual amputation.
ANS: A
A nonhealing wound needs the expertise of the wound care nurse. Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The patient may need an amputation, but other options need to be tried first.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Peripheral vascular disease | consultation | wound care
MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A patient has peripheral arterial disease (PAD). What statement by the patient indicates misunderstanding about self-management activities?
a. “I can use a heating pad on my legs if it’s set on low.”
b. “I should not cross my legs when sitting or lying down.”
c. “I will go out and buy some warm, heavy socks to wear.”
d. “It’s going to be really hard but I will stop smoking.”
ANS: A
Patients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.
PTS: 1 DIF: Cognitive Level: Evaluating
KEY: Peripheral arterial disease | patient education | patient safety
MSC: Integrated Process: Nursing Process/Evaluation
NOT: Patient Needs Category: Health Promotion and Maintenance