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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.
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The nurse is assessing a patient who was admitted with heart failure and notes that the patient has jugular venous distension (JVD) when lying flat in bed. Which of the following actions should the nurse take next?
- A. Use a ruler to measure the level of the JVD.
- B. Document this finding in the patient's record.
- C. Observe for JVD with the head at 45 degrees.
- D. Have the patient perform the Valsalva manoeuvre.
Correct Answer: C
Rationale: When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not clinically significant) finding. JVD that persists when the patient is sitting at a 45-degree angle or greater is significant. The nurse may use a ruler to determine the level of JVD above the heart if the JVD persists when the patient is at a 45-degree angle or more. JVD is an expected finding when a patient performs the Valsalva manoeuvre because right atrial pressure increases. The nurse will document the JVD in the record if it persists when the head is elevated.
Which of the following actions should the nurse implement for a patient who arrives for a calcium-scoring CT scan?
- A. Administer oral sedative medications.
- B. Teach the patient about the procedure.
- C. Ask whether the patient has eaten today.
- D. Insert a large gauge intravenous catheter.
Correct Answer: B
Rationale: The nurse will need to teach the patient that the procedure is rapid and involves little risk. The other actions are not necessary.
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 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 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.