Nokea
The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefully monitors the flow rate of the IV infusion because rapid infusion can cause which disorder?
- A. hypotension.
- B. thrombophlebitis.
- C. pulmonary emboli.
- D. heart failure.
Correct Answer: D
Rationale: Heart failure can result from rapid infusion of intravenous fluids in older adults.
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The nurse reinforcing a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for which change?
- A. reduction of alcohol intake.
- B. avoiding cold remedies.
- C. cessation of smoking.
- D. weight reduction.
Correct Answer: C
Rationale: The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger disease.
The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient makes which statement?
- A. I can ambulate in the hallway with this gadget on.'
- B. I always take off the telemetry device when I shower.'
- C. My EKG is being watched by one of the nurses in CCU on the home unit.'
- D. I am able to sleep just fine with this device on.'
Correct Answer: B
Rationale: Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower.
Which intervention is appropriate for a patient who is experiencing an acute attack of Raynaud's disease?
- A. Vigorously rub both the hands in ice or snow.
- B. Place the hands in ice water to observe for pallor.
- C. Apply hot water over both the hands to rapidly warm the hands.
- D. Place mittens on the hands and encourage the patient to move fingers.
Correct Answer: D
Rationale: For an acute attack, the patient should wear layers such as mittens, and move the fingers and hands to improve circulation. Placing the hands in ice, snow or ice water would worsen the arterial constriction. Applying hot water would cause serious burns.
A 70 year female patient arrives to the emergency department, reporting nausea, vomiting, fatigue and abdominal discomfort. The health care provider requests myocardial infarction (MI) protocols to begin. For which reason is this protocol beginning?
- A. The provider is concerned a lawsuit could occur due to missed diagnosis.
- B. Women tend to have less classic symptoms of a myocardial infarction.
- C. Women are more likely to die from breast or cervical cancer than an MI.
- D. The troponin I level is not as accurate for females as it is in male patients.
Correct Answer: B
Rationale: Women experiencing an MI tend to experience symptoms that are unrelated to chest pain: nausea, vomiting, fatigue, indigestion, shortness of breath, and upper back or abdominal discomfort.
The older adult patient with angina pectoris says she is unsure how she should take nitroglycerin when she has an attack. The nurse should reinforce which instruction?
- A. Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is relieved.'
- B. If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your health care provider and come to the hospital.'
- C. When nitroglycerin is not relieving the pain, lie down and rest.'
- D. Use oxygen at home to relieve pain when nitroglycerin is not successful.'
Correct Answer: B
Rationale: Administer prescribed nitroglycerin. Repeat every 5 minutes, three times. If pain is unrelieved, notify the health care provider. Nitroglycerin administered sublingually usually relieves angina symptoms but does not relieve the pain from an MI. Administering nitroglycerin more than three times will probably not relieve the pain.