Nokea
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of the following actions included in the standard TEE orders should the nurse accomplish first?
- A. Administer O2 per mask.
- B. Start a large-gauge IV line.
- C. Place the patient on NPO status.
- D. Give lorazepam 1 mg IV.
Correct Answer: C
Rationale: The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure.
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The nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill. Which of the following assessment findings requires the most rapid action by the nurse?
- A. Patient complaint of feeling tired
- B. Pulse change from 80 to 96 beats/minute
- C. BP increase from 134/68 to 150/80 mm Hg
- D. Electrocardiographic changes indicating coronary ischemia
Correct Answer: D
Rationale: ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment depression) indicate that the myocardium is not getting adequate oxygen delivery and that the exercise test should be terminated immediately. Increases in BP and heart rate (HR) are normal responses to aerobic exercise. Tiredness also is normal as the intensity of exercise increases during the stress testing.
The nurse is assessing a patient who has just arrived in the emergency department and notes a pulse deficit. Which of the following actions should the nurse anticipate for the patient?
- A. A 2-D echocardiogram
- B. A cardiac catheterization
- C. Hourly blood pressure checks
- D. Electrocardiogram monitoring
Correct Answer: D
Rationale: Pulse deficit is a difference between simultaneously obtained apical and radial pulses and indicates that there may be a cardiac dysrhythmia that would be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and echocardiograms are used for diagnosis of other cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit.
The nurse is assessing the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. Which of the following laboratory results is most important for the nurse to review?
- A. LDL cholesterol
- B. Troponins T and I
- C. C-reactive protein
- D. Creatine kinase-MB (CK-MB)
Correct Answer: B
Rationale: Cardiac troponins start to elevate hours (average 4-6 hours) after myocardial injury and are specific to myocardium. Creatine kinase-MB (CK-MB) is specific to myocardial injury and infarction, but it does not increase until 6 hours after the infarction occurs. LDL cholesterol and C-reactive protein are useful in assessing cardiovascular risk but are not helpful in determining whether a patient is having an acute myocardial infarction.
The nurse is providing teaching to a patient being evaluated for rhythm disturbances with a Holter monitor. Which of the following information should the nurse include in the teaching plan?
- A. Exercise more than usual while the monitor is in place.
- B. Remove the electrodes when taking a shower or tub bath.
- C. Keep a diary of daily activities while the monitor is worn.
- D. Connect the recorder to a telephone transmitter once daily.
Correct Answer: C
Rationale: The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient's rhythm until the end of the testing, when it is removed and the data are analyzed.
The nurse is caring for a patient who is being treated for heart failure. Which of the following laboratory results should the nurse assess to determine the effects of therapy?
- A. Myoglobin
- B. Homocysteine (Hcy)
- C. Low-density lipoprotein (LDL)
- D. B-type natriuretic peptide (BNP)
Correct Answer: D
Rationale: Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (myoglobin) or risk for coronary artery disease (Hcy and LDL).