Nokea
A client comes to the emergency department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would the nurse suspect in this client?
- A. Coronary artery disease
- B. Raynaud syndrome
- C. Cardiogenic shock
- D. Venous occlusive disease
Correct Answer: A
Rationale: The classic symptom of CAD is chest pain (angina) or discomfort during activity or stress. Such pain or discomfort typically is manifested as sudden pain or pressure that may be centered over the heart (precordial) or under the sternum (substernal). Raynaud syndrome in the hands presents with symptoms of hands that are cold, blanched, and wet with perspiration. Cardiogenic shock is a complication of an MI. Venous occlusive disease occurs in the veins, not the arteries.
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A client is prescribed a nitroglycerin transdermal patch to treat angina. Which statement does the nurse include when reinforcing medication teaching to the client prior to discharge?
- A. You do not need the effects of this medication while you sleep
- B. The medication patch causes headaches so you should remove it daily
- C. The patch should be worn for 12 hours and then removed for 12 hours
- D. Skin irritation is common when the patch is worn for more than 12 hours
Correct Answer: C
Rationale: A transdermal nitroglycerin patch is prescribed for the prevention of angina pectoris. Nitroglycerin transdermal patches are typically applied for 12 to 14 hours, and then removed for the same amount of time. Though it is true that common adverse effects of nitroglycerin are headaches and contact dermatitis and that there is less demand on the heart when the client rests, these are not the reasons for applying and removing the patch for the same length of time in a 24-hour period.
The nurse is caring for a client who is status postoperative from a vein stripping. What would the nurse monitor for in the client?
- A. Swelling in the inoperative leg
- B. Blood on the dressing on the inoperative leg
- C. Warm, pink toes in the inoperative leg
- D. Swelling in the operative leg
Correct Answer: D
Rationale: When the client returns from surgery with a gauze dressing covered by elastic roller bandages on the operative leg, the nurse monitors for swelling in the operative leg(s) and its effect on circulation.
The nurse provides care for a client following a percutaneous transluminal coronary angioplasty (PTCA). Which is the priority action by the nurse?
- A. Monitor the gag reflex
- B. Evaluate for signs of infection
- C. Monitor for signs of fluid volume deficit
- D. Palpate distal pulses in bilateral extremities
Correct Answer: D
Rationale: The PTCA is an invasive nonsurgical procedure in which a balloon-tipped catheter is inserted and threaded through a peripheral artery. The nurse monitors the client for bleeding postprocedure in addition to palpating distal, bilateral pulses in the appropriate extremity. Fluid volume deficit is not a primary concern. This procedure does not require general anesthesia; therefore, monitoring for an impaired gag reflex is not a priority nursing action. Signs of infection should be monitored post-PTCA, but this is not an immediate concern.
Which assessment finding by the nurse is the most significant finding suggestive of aortic aneurysm?
- A. High blood pressure
- B. Severe back pain
- C. Abdomen bruit
- D. Nausea and vomiting
Correct Answer: C
Rationale: A pulsating mass or a bruit in the abdomen over the mass is most suggestive of aortic aneurysm. Severe back pain, nausea, and high blood pressure are all symptoms associated with aortic aneurysm but not as independently suggestive.
A client with venous insufficiency is instructed to exercise, apply elastic stockings, and elevate the extremities. Which is the primary benefit for this nursing management regimen?
- A. Improve arterial flow
- B. Strengthen venous valves
- C. Increase venous congestion
- D. Improve venous return
Correct Answer: D
Rationale: The major goal in management of venous insufficiency is to promote venous circulation. Arterial flow improvement is not the goal of treatment for this disorder. Venous valves that are incompetent cannot be strengthened. Venous congestion is a complication of venous insufficiency.