Nokea
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.
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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.
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 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.
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).
Which of the following information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI?
- A. The patient has an allergy to shellfish and iodine.
- B. The patient has a history of coronary artery disease.
- C. The patient has a permanent ventricular pacemaker in place.
- D. The patient took all the prescribed cardiac medications today.
Correct Answer: C
Rationale: MRI is contraindicated for patients with implanted metallic devices such as pacemakers as the magnets can alter the function of the device. The other information also will be reported to the health care provider but does not impact whether or not the patient can have an MRI.