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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.
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The RN is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse implements which of the following interventions?
- A. Places the patient in the left lateral position to check for the point of maximal impulse (PMI).
- B. Presses on the skin over the tibia for 10 seconds to check for edema.
- C. Palpates both carotid arteries simultaneously to compare pulse quality.
- D. Documents a murmur heard along the left sternal border as an aortic murmur.
Correct Answer: C
Rationale: The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected. However, they are not dangerous to the patient.
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 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 caring for a patient who is scheduled for a cardiac catheterization with coronary angiography. Which of the following information should the nurse provide to the patient before the test?
- A. Electrocardiographic (ECG) monitoring will be required for 24 hours after the test.
- B. It will be important to lie completely still during the procedure.
- C. A warm feeling may be noted when the contrast dye is injected.
- D. Monitored anaesthesia care will be provided during the procedure.
Correct Answer: C
Rationale: A sensation of warmth or flushing is common when the iodine-based contrast material is injected, which can be anxiety-producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure, but monitored anaesthesia care is not used. ECG monitoring is used during the procedure to detect dysrhythmias, but there is not a risk for dysrhythmias after the procedure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.
The nurse is assessing an underweight older-adult patient and observes pulsation of the abdominal aorta in the epigastric area. Which of the following actions should the nurse take?
- A. Notify the hospital rapid response team.
- B. Instruct the patient to remain on bed rest.
- C. Teach the patient about aortic aneurysms.
- D. Document the finding in the patient chart.
Correct Answer: D
Rationale: Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals and the nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.