Nokea
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.
You may also like to solve these questions
When assessing a patient with a possible myocardial infarction (MI), which sign or symptom should the nurse assess for?
- A. Pain radiating to left arm and jaw
- B. Visual Hallucinations
- C. Pallor
- D. Diaphoresis
- E. Apprehension
- F. Dyspnea
Correct Answer: A,C,D,E,F
Rationale: Pain radiating to the left arm and jaw, pallor, diaphoresis, apprehension/anxiety and dyspnea are signs and symptoms present in patients with an MI.
The nurse caring for a patient recovering from a myocardial infarction (MI) administers stool softeners for which reason?
- A. Prevent enema dependence in the hospitalized patient
- B. Prevent fecal impactions which can lead to bowel obstruction
- C. Stool softeners reduce the need for laxatives once the patient is discharged
- D. Reduce the necessity to strain at the stool to lessen the effect of Valsalva's maneuver
Correct Answer: D
Rationale: Stool softeners will lessen the severity of straining and will decrease the effect of the Valsalva's maneuver on intrathoracic pressure.
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.
The nurse recognizes the echocardiogram report that shows an ejection factor of $42 \%$ as an indication of which situation?
- A. normal heart action.
- B. mild heart failure.
- C. moderate heart failure.
- D. severe heart failure.
Correct Answer: C
Rationale: An ejection fraction (cardiac output) of $42 \%$ indicates moderate heart failure.
Which information should be taught to patients starting on anticoagulant therapy for a valvular disorder?
- A. Increase the dose of aspirin for better therapy.
- B. Take medication at the same time each day.
- C. Report to health care provider cuts that do not stop bleeding with direct pressure.
- D. No restrictions for food or drink.
- E. Report for prescribed blood tests (PTT, INR, CBC, blood sugar).
Correct Answer: B,C
Rationale: Aspirin should not be used with anticoagulant therapy because it will increase bleeding. Gums, nosebleeds, excessive bruising, and cuts that do not stop bleeding with direct pressure should be reported to the health care provider. Alcohol and dark green and yellow vegetables should be avoided because they contain vitamin K. Normal blood tests for anticoagulant therapy are PTT, INR, and PT.