Nokea
The student nurse is preparing a teaching plan for a patient being discharged status post MI. What should the student include in the teaching plan? (Mark all that apply.)
- A. Need for careful monitoring for cardiac symptoms
- B. Need for carefully regulated exercise
- C. Need for dietary modifications
- D. Need for early resumption of prediagnosis activity
- E. Need for increased fluid intake
Correct Answer: A,B,C
Rationale: Dietary modifications, exercise, weight loss, and careful monitoring are important strategies for managing three major cardiovascular risk factors: hyperlipidemia, hypertension, and diabetes. There is no need to increase fluid intake and activity should be slowly and deliberately increased.
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A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what?
- A. Systole
- B. Diastole
- C. Repolarization
- D. Ejection fraction
Correct Answer: A
Rationale: Systole is the action of the chambers of the heart becoming smaller and ejecting blood. This action of the heart is not diastole (relaxations), ejection fraction (the amount of blood expelled), or repolarization (electrical charging).
A critically ill patient is admitted to the ICU. The physician decides to use intra-arterial pressure monitoring. After this intervention is performed, what assessment should the nurse prioritize in the plan of care?
- A. Fluctuations in core body temperature
- B. Signs and symptoms of esophageal varices
- C. Signs and symptoms of compartment syndrome
- D. Perfusion distal to the insertion site
Correct Answer: D
Rationale: The radial artery is the usual site selected. However, placement of a catheter into the radial artery can further impede perfusion to an area that has poor circulation. As a result, the tissue distal to the cannulated artery can become ischemic or necrotic. Vigilant assessment is thus necessary. Alterations in temperature and the development of esophageal varices or compartment syndrome are not high risks.
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.
The nurse is performing an intake assessment on a patient with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment?
- A. Whether the patient and involved family members understand the role of genetics in the etiology of the disease
- B. Whether the patient and involved family members understand dietary changes and the role of nutrition
- C. Whether the patient and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately
- D. Whether the patient and involved family members understand the importance of social support and community agencies
Correct Answer: C
Rationale: During the health history, the nurse needs to determine if the patient and involved family members are able to recognize symptoms of an acute cardiac problem, such as acute coronary syndrome (ACS) or HF, and seek timely treatment for these symptoms. Each of the other listed topics is valid, but the timely and appropriate response to a cardiac emergency is paramount.
The nurse is caring for a patient who has central venous pressure (CVP) monitoring in place. The nurses most recent assessment reveals that CVP is 7 mm Hg. What is the nurses most appropriate action?
- A. Arrange for continuous cardiac monitoring and reposition the patient
- B. Remove the CVP catheter and apply an occlusive dressing
- C. Assess the patient for fluid overload and inform the physician
- D. Raise the head of the patients bed and have the patient perform deep breathing exercise, if possible
Correct Answer: C
Rationale: The normal CVP is 2 to 6 mm Hg. Many problems can cause an elevated CVP, but the most common is due to hypervolemia. Assessing the patient and informing the physician are the most prudent actions. Repositioning the patient is ineffective and removing the device is inappropriate.