Nokea
A nurse is describing one of the waveforms to a novice critical care nurse. S/he describes this wave as being upright rounded and symmetrical and occurring after the QRS. The nurse is describing the
- A. P wave
- B. QRS
- C. ST segment
- D. T wave
Correct Answer: D
Rationale: The correct answer is D: T wave. The T wave is upright, rounded, and symmetrical, occurring after the QRS complex on an ECG. This wave represents ventricular repolarization. The P wave (Choice A) represents atrial depolarization, the QRS complex (Choice B) represents ventricular depolarization, and the ST segment (Choice C) represents the period between ventricular depolarization and repolarization. Therefore, the T wave is the only waveform that fits the description given in the question.
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In preparing the patient for insertion of a pulmonary artery catheter, the nurse
- A. Obtains informed consent
- B. Places the patient in a high Fowler's position
- C. Ensures that the patient has continuous ECG monitoring
- D. Performs an Allen test to confirm adequate ulnar circulation
Correct Answer: C
Rationale: The correct answer is C because continuous ECG monitoring is crucial during pulmonary artery catheter insertion to detect any arrhythmias or changes in cardiac status promptly. This ensures the patient's safety and allows for immediate intervention if needed. Obtaining informed consent (choice A) is important but not specific to this procedure. Placing the patient in a high Fowler's position (choice B) may be necessary for comfort but is not directly related to the insertion process. Performing an Allen test (choice D) is not typically required for pulmonary artery catheter insertion.
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 are indicative of possible pulmonary edema, a common complication post-STEMI that requires immediate medical attention to prevent respiratory distress. Reporting this symptom promptly can help the provider initiate appropriate interventions.
A: Elevated troponin levels are expected post-STEMI and are not typically an acute concern after 2 days.
B: Patient denial of heart attack history may indicate a lack of awareness but does not require immediate intervention.
D: Occasional premature atrial contractions are common and not typically urgent in the context of a recent STEMI.
In planning for pain management for a client with thrombophlebitis the nurse should include
- A. prescribed analgesics
- B. prescribed anticoagulants
- C. exercise
- D. bed rest
Correct Answer: D
Rationale: The correct answer is D: bed rest. Bed rest is crucial for managing thrombophlebitis to prevent further clot formation and reduce the risk of complications. Movement can dislodge blood clots, leading to embolism. Analgesics (A) may help with pain but do not address the underlying issue. Anticoagulants (B) are used to prevent clot formation but do not directly manage pain. Exercise (C) can worsen thrombophlebitis by increasing the risk of clot dislodgment. Thus, bed rest is the most appropriate option for pain management in thrombophlebitis.
A client with endocarditis develops sudden leg pain with pallor, tingling, and loss of peripheral pulses. The nurse's initial action should be to:
- A. Elevate the leg above the level of the heart.
- B. Wrap the leg in a loose blanket.
- C. Notify the physician about the findings.
- D. Perform passive ROM exercises to stimulate circulation.
Correct Answer: C
Rationale: The correct initial action is to notify the physician (Choice C) about the sudden onset of leg pain, pallor, tingling, and loss of pulses, as these symptoms suggest acute arterial occlusion, a medical emergency. The physician needs to be informed immediately to assess the situation and determine the appropriate intervention, such as urgent revascularization. Elevating the leg (Choice A) may worsen the condition by reducing blood flow further. Wrapping the leg in a blanket (Choice B) is not recommended as it does not address the underlying arterial occlusion. Passive ROM exercises (Choice D) are contraindicated in this situation as they can potentially dislodge blood clots and exacerbate the blockage.
As the manager of a cardiac surgery unit, you are responsible for developing a standardized care plan for the post-operative care of patients having cardiac surgery. Which of these nursing activities included in the care plan will need to be done by an RN?
- A. Remove chest and leg dressings on the second post-operative day and clean the incisions with antibacterial swabs.
- B. Reinforce patient and family teaching about the need to deep breathe and cough at least every 2 hours while awake.
- C. Develop individual plan for discharge teaching based on discharge medications and needed lifestyle changes.
- D. Administer oral analgesic medications as needed prior to assisting patient out of bed on first post-operative day.
Correct Answer: C
Rationale: The correct answer is C because developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes requires critical thinking, assessment, and evaluation skills, which are within the scope of practice of a registered nurse (RN). RNs are trained to assess patients' needs, plan and implement care, and evaluate outcomes. Removing dressings (choice A) and administering medications (choice D) are tasks that can be delegated to other healthcare team members such as licensed practical nurses or nursing assistants. Reinforcing patient and family teaching (choice B) can also be done by other healthcare team members under the supervision of an RN.