Nokea
A newly admitted patient, diagnosed with a myocardial infarction and left ventricular heart failure might exhibit which of the following physical symptoms? Choose all that apply.
- A. Jugular vein distention
- B. Hepatomegaly
- C. Dyspnea
- D. Crackles
Correct Answer: A
Rationale: The correct answer is A: Jugular vein distention. In patients with left ventricular heart failure, increased pressure in the heart can lead to jugular vein distention due to backflow of blood. This is a common physical symptom seen in such patients.
Incorrect choices:
- B: Hepatomegaly is not a typical physical symptom of left ventricular heart failure. It may be seen in conditions like liver cirrhosis.
- C: Dyspnea is a common symptom in heart failure but is not specific to left ventricular heart failure.
- D: Crackles are indicative of fluid accumulation in the lungs, which is more common in right-sided heart failure rather than left ventricular heart failure.
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Your patient is experiencing thrombophlebitis. Which of the following medications would you expect to administer for this condition?
- A. Heparin.
- B. Lisinopril.
- C. Amiodarone.
- D. Furosemide.
Correct Answer: A
Rationale: The correct answer is A: Heparin. Heparin is an anticoagulant that helps prevent blood clot formation, which is crucial in treating thrombophlebitis. It works by inhibiting clotting factors and preventing further clot growth.
B: Lisinopril is an ACE inhibitor used for hypertension, not thrombophlebitis.
C: Amiodarone is an antiarrhythmic medication used for heart rhythm disorders, not thrombophlebitis.
D: Furosemide is a diuretic used for edema and high blood pressure, not thrombophlebitis.
Which assessment is the most important in determining the amount of fluid that the client is retaining?
- A. Heart sounds
- B. Peripheral pulses
- C. Daily weights
- D. Peripheral edema
Correct Answer: C
Rationale: The correct answer is C: Daily weights. Daily weights are crucial in monitoring fluid retention as they provide a direct measure of changes in the body's fluid balance. Sudden weight gain can indicate fluid retention, such as in heart failure. Heart sounds (A) are important for assessing heart function but do not directly measure fluid retention. Peripheral pulses (B) are mainly used to assess circulation and not fluid retention. Peripheral edema (D) is a visible sign of fluid retention, but daily weights provide a more accurate and quantitative measure of fluid status.
A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when scheduling this medication?
- A. Administer the medication at the patient’s usual bedtime.
- B. Have the patient take the colesevelam 1 hour before breakfast.
- C. Give the patient’s other medications 2 hours after colesevelam.
- D. Have the patient take the dose at the same time as the prescribed aspirin.
Correct Answer: B
Rationale: The correct answer is B: Have the patient take the colesevelam 1 hour before breakfast. This is because colesevelam should be taken with a meal and liquid. By taking it before breakfast, the patient ensures that the medication is ingested with adequate food and fluid to optimize its therapeutic effect. Option A is incorrect as there is no specific requirement to take colesevelam at bedtime. Option C is incorrect as there is no need to separate colesevelam from other medications by 2 hours. Option D is incorrect as there is no indication that colesevelam should be taken with aspirin.
A patient comes to the emergency department (ED) and reports a swollen and painful leg but denies sustaining any injury. The physical examination reveals a tense calf muscle, decreased sensation to the foot and leg, and absent pedal pulses. The cardiac-vascular nurse asks the patient when the symptoms began because:
- A. arterial thrombosis is sudden and emergent, and an embolism develops gradually.
- B. compartment syndrome develops days after an arterial occlusion.
- C. irreversible anoxic injury to muscles and nerves can occur in as few as four hours.
- D. metabolic alkalosis from muscle swelling is cardiotoxic.
Correct Answer: C
Rationale: The correct answer is C because irreversible anoxic injury to muscles and nerves can occur in as few as four hours in cases of acute arterial occlusion. This is a medical emergency requiring immediate intervention to restore blood flow and prevent tissue damage.
A: Arterial thrombosis and embolism both lead to sudden occlusion of blood vessels, but the focus here is on the rapid onset of irreversible tissue damage, not the timing of symptom development.
B: Compartment syndrome usually occurs hours to days after arterial occlusion, not days after. However, the key here is the potential for irreversible anoxic injury within a shorter timeframe.
D: Metabolic alkalosis from muscle swelling is not directly related to the symptoms described and is not cardiotoxic in this context.
The 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?
- A. The troponin level is elevated.
- B. The patient denies having a heart attack.
- C. Bilateral crackles in the mid-lower lobes.
- D. Occasional premature atrial contractions (PACs).
Correct Answer: C
Rationale: The correct answer is C, bilateral crackles in the mid-lower lobes. This finding indicates potential heart failure, a serious complication post-STEMI. Reporting this promptly to the healthcare provider allows for timely intervention to prevent further deterioration. Choice A, an elevated troponin level, is expected post-STEMI and may not require immediate action. Choice B, the patient denying a heart attack, is not as critical as the physical assessment findings. Choice D, occasional PACs, is common and may not be directly related to the patient's current condition.