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A critically ill patient is admitted to the ICU. The physician decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize in the plan of care?
- A. Fluctuations in core body temperature
- B. Signs and symptoms of esophageal varices
- C. Signs and symptoms of compartment syndrome
- D. Perfusion distal to the insertion site
Correct Answer: D
Rationale: The radial artery is the usual site selected. However, placement of a catheter into the radial artery can further impede perfusion to an area that has poor circulation. As a result, the tissue distal to the cannulated artery can become ischemic or necrotic. Vigilant assessment is thus necessary. Alterations in temperature and the development of esophageal varices or compartment syndrome are not high risks.
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The nurse is performing an intake assessment on a patient with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment?
- A. Whether the patient and involved family members understand the role of genetics in the etiology of the disease
- B. Whether the patient and involved family members understand dietary changes and the role of nutrition
- C. Whether the patient and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately
- D. Whether the patient and involved family members understand the importance of social support and community agencies
Correct Answer: C
Rationale: During the health history, the nurse needs to determine if the patient and involved family members are able to recognize symptoms of an acute cardiac problem, such as acute coronary syndrome (ACS) or HF, and seek timely treatment for these symptoms. Each of the other listed topics is valid, but the timely and appropriate response to a cardiac emergency is paramount.
The nurse is calculating a cardiac patients pulse pressure. If the patients blood pressure is 122/76 mm Hg, what is the patients pulse pressure?
- A. 46 mm Hg
- B. 99 mm Hg
- C. 198 mm Hg
- D. 76 mm Hg
Correct Answer: A
Rationale: Pulse pressure is the difference between the systolic and diastolic pressure. In this case, this value is 46 mm Hg (122 - 76 = 46).
The nurses assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the patients plan of care?
- A. Risk for ineffective breathing pattern related to hypotension
- B. Risk for falls related to orthostatic hypotension
- C. Risk for ineffective role performance related to hypotension
- D. Risk for imbalanced fluid balance related to hemodynamic variability
Correct Answer: B
Rationale: Orthostatic hypotension creates a significant risk for falls due to the dizziness and lightheadedness that accompanies it. It does not normally affect breathing or fluid balance. The patients ability to perform normal roles may be affected, but the risk for falls is the most significant threat to safety.
The nurse is caring for an 82-year-old patient. The nurse knows that changes in cardiac structure and function occur in older adults. What is a normal change expected in the aging heart of an older adult?
- A. Decreased left ventricular ejection time
- B. Decreased connective tissue in the SA and AV nodes and bundle branches
- C. Thinning and flaccidity of the cardiac valves
- D. Widening of the aorta
Correct Answer: D
Rationale: Changes in cardiac structure and function are clearly observable in the aging heart. Aging results in decreased elasticity and widening of the aorta, thickening and rigidity of the cardiac valves, increased connective tissue in the SA and AV nodes and bundle branches, and an increased left ventricular ejection time (prolonged systole).
A patient has been scheduled for cardiovascular computed tomography (CT) with contrast. To prepare the patient for this test, what action should the nurse perform?
- A. Keep the patient NPO for at least 6 hours prior to the test
- B. Establish peripheral IV access
- C. Limit the patients activity for 2 hours before the test
- D. Teach the patient to perform incentive spirometry
Correct Answer: B
Rationale: An IV is necessary if contrast is to be used to enhance the images of the CT. The patient does not need to fast or limit his or her activity. Incentive spirometry is not relevant to this diagnostic test.