Nokea
The nurses assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should consequently identify what nursing diagnosis in the patients plan of care?
- A. Risk for ineffective breathing pattern related to hypotension
- B. Risk for falls related to orthostatic hypotension
- C. Risk for ineffective role performance related to hypotension
- D. Risk for imbalanced fluid balance related to hemodynamic variability
Correct Answer: B
Rationale: Orthostatic hypotension creates a significant risk for falls due to the dizziness and lightheadedness that accompanies it. It does not normally affect breathing or fluid balance. The patients ability to perform normal roles may be affected, but the risk for falls is the most significant threat to safety.
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A patient has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. You are aware that the damage occurred where?
- A. Endocardium
- B. Pericardium
- C. Myocardium
- D. Visceral pericardium
Correct Answer: C
Rationale: The myocardium is the layer of the heart responsible for the pumping action.
The patient has a homocysteine level ordered. What aspects of this test should inform the nurses care? Select all that apply.
- A. A 12-hour fast is necessary before drawing the blood sample
- B. Recent inactivity can depress homocysteine levels
- C. Genetic factors can elevate homocysteine levels
- D. A diet low in folic acid elevates homocysteine levels
- E. An ECG should be performed immediately before drawing a sample
Correct Answer: A,C,D
Rationale: Genetic factors and a diet low in folic acid, vitamin B6, and vitamin B12 are associated with elevated homocysteine levels. A 12-hour fast is necessary before drawing a blood sample for an accurate serum measurement. An ECG is unnecessary and recent inactivity does not influence the results of the test.
The nurse is caring for a patient who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output?
- A. A change in position from standing to sitting
- B. A heart rate of 54 bpm
- C. A pulse oximetry reading of 94%
- D. An increase in preload related to ambulation
Correct Answer: B
Rationale: Cardiac output is computed by multiplying the stroke volume by the heart rate. Cardiac output can be affected by changes in either stroke volume or heart rate, such as a rate of 54 bpm. An increase in preload will lead to an increase in stroke volume. A pulse oximetry reading of 94% does not indicate hypoxemia, as hypoxia can decrease contractility. Transitioning from standing to sitting would more likely increase rather than decrease cardiac output.
The critical care nurse is caring for a patient who has been experiencing bradycardia after cardiovascular surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent firing rate. Under normal circumstances where are these cells located?
- A. SA node
- B. AV node
- C. Bundle of His
- D. Purkinje cells
Correct Answer: A
Rationale: The heart rate is determined by the myocardial cells with the fastest inherent firing rate. Under normal circumstances, the SA node has the highest inherent rate (60 to 100 impulses per minute).
The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding?
- A. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours
- B. Because the patient has a history of unstable angina, this is a poor indicator of myocardial injury
- C. This is an accurate indicator of myocardial injury
- D. This result indicates muscle injury, but does not specify the source
Correct Answer: C
Rationale: Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even with a diagnosis of unstable angina, this is an accurate indicator of myocardial injury.