Nokea
The nurse clarifies that which is the area of the heart that normally initiates electrical impulses?
- A. left ventricle.
- B. atrioventricular (AV) node.
- C. sinoatrial (SA) node.
- D. bundle of His.
Correct Answer: C
Rationale: The SA node is the master pacemaker of the heart.
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The patient, age 26, is hospitalized with cardiomyopathy. While assisting with data collection from the patient, the nurse recognizes that the increased incidence of cardiomyopathy in young adults who have minimal risk factors for cardiovascular disease is related to which factor?
- A. Cocaine use
- B. Viral infection
- C. Vitamin B1 deficiency
- D. Pregnancy
Correct Answer: A
Rationale: Cardiomyopathy caused by cocaine abuse triggers intense vasoconstriction of the coronary arteries and peripheral vasoconstriction. Cocaine also causes high circulating levels of catecholamines, which may further damage myocardial cells, leading to ischemic or dilated cardiomyopathy. The cardiomyopathy produced is difficult to treat. Interventions deal mainly with the HF that ensues.
The nurse reminds the patient who is taking warfarin for the treatment of peripheral artery disease not to eat excessive green and yellow vegetables for which reason?
- A. Potassium in the vegetables can cause additional bleeding
- B. Green and yellow vegetables cause loose bowel movements
- C. Vitamin $\mathrm{K}$ in the vegetables counteracts the anticoagulant effect
- D. Potassium in the vegetables can cause hyperkalemia to develop
Correct Answer: C
Rationale: The patient taking warfarin should not eat excessive amounts of vitamin $\mathrm{K}$ containing foods, such as green and yellow vegetables. Vitamin $\mathrm{K}$ counteracts the anticoagulant effect, and blood clots could develop.
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.
The nurse assesses pitting edema that can be depressed approximately $4 \mathrm{~mm}$ and refills in 15 seconds. The nurse would document this assessment as:
- A. +1 edema.
- B. +2 edema.
- C. +3 edema.
- D. +4 edema.
Correct Answer: B
Rationale: A +2 edema can be documented if the skin can be depressed $4 \mathrm{~mm}$ and respond within 15 seconds.
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.