Nokea
A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects?
- A. Nervousness or paresthesia
- B. Throbbing headache or dizziness
- C. Drowsiness or blurred vision
- D. Tinnitus or diplopia
Correct Answer: B
Rationale: Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.
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The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs?
- A. The patient experiences chest pain, palpitations, or dyspnea
- B. The patient experiences a noticeable increase in heart rate during activity
- C. The patients oxygen saturation level drops below 96%
- D. The patients respiratory rate exceeds 30 breaths/min
Correct Answer: A
Rationale: Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most patients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.
A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in her femoral region. What is the nurses most appropriate action?
- A. Call for assistance and initiate cardiopulmonary resuscitation
- B. Reposition the patients leg in a nondependent position
- C. Promptly remove the femoral sheath
- D. Call for help and apply pressure to the access site
Correct Answer: D
Rationale: The femoral sheath produces pressure on the access site. Pressure will temporarily reduce bleeding and allow for subsequent interventions. Removing the sheath would exacerbate bleeding and repositioning would not halt it. CPR is not indicated unless there is evidence of respiratory or cardiac arrest.
An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what?
- A. Brachial artery
- B. Brachial vein
- C. Femoral artery
- D. Greater saphenous vein
Correct Answer: D
Rationale: The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.
You are writing a care plan for a patient who has been diagnosed with angina pectoris. The patient describes herself as being distressed and shocked by her new diagnosis. What nursing diagnosis is most clearly suggested by the womans statement?
- A. Spiritual distress related to change in health status
- B. Acute confusion related to prognosis for recovery
- C. Anxiety related to cardiac symptoms
- D. Deficient knowledge related to treatment of angina pectoris
Correct Answer: C
Rationale: Although further assessment is warranted, it is not unlikely that the patient is experiencing anxiety. In patients with CAD, this often relates to the threat of sudden death. There is no evidence of confusion (i.e., delirium or dementia) and there may or may not be a spiritual element to her concerns. Similarly, it is not clear that a lack of knowledge or information is the root of her anxiety.
In preparation for cardiac surgery, a patient was taught about measures to prevent venous thromboembolism. What statement indicates that the patient clearly understood this education?
- A. Ill try to stay in bed for the first few days to allow myself to heal
- B. Ill make sure that I dont cross my legs when Im resting in bed
- C. Ill keep pillows under my knees to help my blood circulate better
- D. Ill put on those compression stockings if I get pain in my calves
Correct Answer: B
Rationale: To prevent venous thromboembolism, patients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge.