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Which statement would lead the nurse to offer more instruction about taking warfarin?
- A. I eat a banana every morning with breakfast.'
- B. I try to eat more green leafy vegetables, especially broccoli, spinach, and kale.'
- C. I try to eat a well-balanced, low-fat diet.'
- D. I don't drink alcohol or caffeine.'
Correct Answer: B
Rationale: Avoid marked changes in eating habits, such as dramatically increasing foods high in vitamin K (e.g., broccoli, spinach, kale, greens). Limit alcohol intake to small amounts.
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What is the third step in the impulse pattern of conduction through the heart?
- A. Atrial wall
- B. Atrial-ventricular (AV) node
- C. Purkinje fibers
- D. Sinoatrial (SA) node
- E. Bundle branches
- F. Bundle of His
Correct Answer: B
Rationale: The conduction begins with the impulse from the SA node that travels down the atrial wall to the AV node, to the Bundle of His, to the bundle branches, and finally to the Purkinje fibers.
The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is coughing up frothy red sputum. What should be the initial nursing intervention?
- A. Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock.
- B. Place patient in side-lying position to reduce the symptoms of atrial fibrillation.
- C. Place patient upright with legs in dependent position to reduce the symptoms of pulmonary edema.
- D. Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock.
Correct Answer: C
Rationale: Signs and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation; disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough producing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; and cold extremities. The legs in a dependent position will decrease venous return and ease the pulmonary edema.
Which assessment would lead the nurse to examine the leg closely for evidence of a stasis ulcer?
- A. Cool dry lower limb
- B. Darker, thick and toughened skin on medial surface of the leg
- C. Lack of hair and shiny appearance of the lower leg
- D. Lack of a pedal pulse
Correct Answer: B
Rationale: Signs of a venous disorder include darker, thick and toughened skin. Venous disorders can lead to a stasis ulcer. Cool hairless limbs with absent or weak pedal pulses are indicative of arterial insufficiency.
The cardiac marker rises 3 hours after a myocardial infarct and measures myocardial contractile protein.
Correct Answer: troponin I
Rationale: Troponin I is a serum cardiac marker that rises 3 hours after an MI and can measure myocardial contractile tissue. Troponin I is not affected by skeletal muscle injury as is troponin T.
The nurse recognizes the echocardiogram report that shows an ejection factor of $42 \%$ as an indication of which situation?
- A. normal heart action.
- B. mild heart failure.
- C. moderate heart failure.
- D. severe heart failure.
Correct Answer: C
Rationale: An ejection fraction (cardiac output) of $42 \%$ indicates moderate heart failure.