Nokea
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.
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To auscultate for S3 or S4 gallops in the mitral area, which of the following should the nurse implement?
- A. Use the bell of the stethoscope with the patient in the left lateral position.
- B. Use the bell of the stethoscope with the patient sitting and leaning forward.
- C. Use the diaphragm of the stethoscope with the patient in a reclining position.
- D. Use the diaphragm of the stethoscope with the patient lying flat on the left side.
Correct Answer: A
Rationale: Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher pitched sounds such as S1 and S2.
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 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).
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.
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.