more nclex from evolve resources
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MORE NCLEX FROM EVOLVE RESOURCES.
1. Upon admission assessment, the nurse notes clubbing of the patient's fingers. Based on this finding, the nurse will question the patient about which of the following disease processes?
A. Endocarditis
B. Acute renal failure
C. Chronic thrombophlebitis
D. Myocardial infarction
Clubbing of the fingers is a loss of the normal angle between the base of the nail and the skin. This finding can be found related to endocarditis, congenital defects, and/or prolonged oxygen deficiency.
Correct Answer: A
2. Which of the following instructions given to a patient who is about to undergo Holter monitoring is most appropriate?
A. “You may remove the monitor only to shower or bathe.”
B. “You should connect the monitor whenever you feel symptoms.”
C. “You will need to keep a diary of all your activities and symptoms.”
D. “You should refrain from exercising while wearing this monitor.”
A Holter monitor is worn for 24 hours while a patient continues with usual activity and keeps a diary of activities and symptoms. The patient should not take a bath or shower while wearing this monitor.
Correct Answer: C
3. The nurse is admitting a patient who is scheduled to undergo a cardiac catheterization. Which of the following allergies is most important for the nurse to assess before this procedure?
A. Aspirin
B. Penicillin
C. Iodine
D. Iron
The physician usually will use an iodine-based contrast to perform this procedure. Therefore it is imperative to know whether or not the patient is allergic to iodine or shellfish.
Correct Answer: C
4. The nurse auscultates the blood pressure of a 71-year-old patient admitted with pneumonia and finds it to be 160/70 mm Hg. Which of the following does the nurse consider to be an age-related change that contributes to this finding?
A. Decreased adrenergic sensitivity
B. Increased parasympathetic activity
C. Stenosis of the heart valves
D. Loss of elasticity in arterial vessels
An age-related change that increases the risk of systolic hypertension is a loss of elasticity in the arterial walls. Because of the increasing resistance to flow, pressure is increased within the blood vessel and hypertension results.
Correct Answer: D
5. The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which of the following mechanisms?
A. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue.
B. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions.
C. Hypertension promotes atherosclerosis and damage to the walls of the arteries.
D. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems.
Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, once atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.
Correct Answer: C
6. When teaching a patient about dietary management of stage 1 hypertension, which of the following instructions is most appropriate?
A. Restrict sodium intake to <2.4 gm/day.
B. Increase use of calcium supplements.
C. Restrict all caffeine.
D. Increase carbohydrate intake.
The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention.
Correct Answer: A
7. In caring for a patient admitted with poorly controlled hypertension, the nurse would understand that which of the following laboratory test results would indicate the presence of target organ damage secondary to the primary diagnosis?
A. Serum uric acid of 3.8 mg/dl
B. Serum creatinine of 2.6 mg/dl
C. Serum potassium of 3.5 mEq/L
D. BUN of 15 mg/dl
The normal serum creatinine level is 0.8 to 1.6 mg/dl. This elevated level indicates target organ damage to the kidneys.
Correct Answer: B
8. When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which of the following meats?
A. Roasted turkey
B. Roasted duck
C. Baked chicken breast
D. Broiled fish
Roasted duck is high in fat, which should be avoided by the patient with hypertension. The other meats are lower in fat and are therefore acceptable in the diet.
Correct Answer: B
9. The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes chlorothiazide daily for the past 10 years. Which of the following parameters would indicate the optimal intended effect of this pharmacologic therapy?
A. Weight loss of 2 lb
B. Absence of ankle edema
C. Blood pressure 128/86
D. Output of 600 ml per shift
Chlorothiazide is used alone as a step 1 approach to managing hypertension or in combination with others if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Since the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.
Correct Answer: C
10. In reviewing medication instructions with a patient being discharged on antihypertensive medications, which of the following statements would be most appropriate for the nurse to make when discussing atenolol (Tenormin)?
A. "Make position changes slowly, especially when going from a lying down position to a standing position."
B. "Because this drug may affect the lungs in large doses, it may also help your breathing."
C. "A fast heart rate is a side effect to watch for while taking atenolol."
D. "Discontinue the drug and notify the prescribing physician if you experience any nausea or vomiting."
Atenolol is a β1-adrenergic blocker and antihypertensive agent that can cause orthostatic hypotension. For this reason, the patient should be instructed to rise slowly, especially when moving from a recumbent to a standing position.
Correct Answer: A
11. The nurse is caring for a patient admitted with emphysema, angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which of the following adverse effects is this patient at risk for given the patient's health history?
A. Hypocapnia
B. Tachycardia
C. Bronchospasm
D. Nausea and vomiting
Atenolol is a cardioselective β1-adrenergic blocker that reduces blood pressure and could affect the β2-receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β-blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD.
Correct Answer: C
12. The nurse is caring for a patient with hypertension who is scheduled to receive a dose of atenolol (Tenormin). The nurse should withhold the dose and consult the prescribing physician for which of the following vital signs taken just before administration?
A. Blood pressure 130/68
B. Pulse 48
C. Respirations 26
D. Oxygen saturation 91%
Because atenolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the prescriber for parameters regarding pulse rate limits.
Correct Answer: B
13. The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease. For which of the following ethnic groups would the nurse select as the highest priority for this intervention?
A. Hispanic female
B. White male
C. African American male
D. Native American female
The incidence of coronary artery disease (CAD) and myocardial infarction (MI) is highest among white, middle-aged men.
Correct Answer: B
14. Which of the following individuals would the nurse identify as having the highest risk for coronary heart disease (CAD)?
A. A 45-year-old depressed male with a high stress job
B. A 60-year-old male with below normal homocysteine levels
C. A 54-year-old female vegetarian with elevated high density lipoprotein (HDL) levels
D. A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2
Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.
Correct Answer: A
15. For which of the following antilipemic medications would the nurse question an order in a patient with cirrhosis of the liver?
A. niacin (Nicobid)
B. ezetimibe (Zetia)
C. atorvastatin (Lipitor)
D. gemfibrozil (Lopid)
Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Thus liver disease is a contraindication for this atorvastatin (Lipitor).
Correct Answer: C
16. After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient states:
A. “I will replace my nitroglycerin supply every 6 months.”
B. “I can take up to five tablets every 3 minutes for relief of my chest pain.”
C. “I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin.”
D. “I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain.”
The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system.
Correct Answer: B
17. When planning emergent care for a patient with a suspected myocardial infarction (MI), the nurse will anticipate administration of:
A. morphine, oxygen, nitroglycerin, and aspirin.
B. furosemide (Lasix) and meperidine (Demerol).
C. nitroprusside (Nipride), dopamine, and dobutamine.
D. lorazepam (Ativan), metolazone (Zaroxolyn), and Coumadin.
The American Heart Association's guidelines for emergency care of the patient with chest pain includes the administration of aspirin, nitroglycerin, morphine, and oxygen. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation.
Correct Answer: A
18. When evaluating a patient's knowledge regarding a low sodium, low fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which of the following food choices?
A. Baked flounder
B. Angel food cake
C. Baked potato with margarine
D. Canned chicken noodle soup
Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.
Correct Answer: D
19. Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for which of the following common complications?
A. Dehydration
B. Paralytic ileus
C. Atrial dysrhythmias
D. Acute respiratory distress syndrome
Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days following CABG surgery. Although the other complications could occur, they are not common complications.
Correct Answer: C
20. The nurse is providing teaching to a patient recovering from a myocardial infarction (MI). Discussion regarding resumption of sexual activity should be:
A. delegated to the primary care provider.
B. avoided because it is embarrassing to the patient.
C. discussed along with other physical activities.
D. accomplished by providing the patient with written material.
Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the individual patient's questions and concerns.
Correct Answer: C
21. The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which of the following symptoms?
A. Anorexia and nausea
B. Muscle aches
C. Pounding headache
D. Constipation
Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the prescriber if the patient exhibited any of these symptoms.
Correct Answer: A
22. The nurse is preparing to administer digoxin to a patient with HF. In preparation, lab results are reviewed with the following findings: sodium 139 mEq/L, potassium 3.0 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dl. The nurse should do which of the following at this time?
A. Give the digoxin with a salty snack, such as crackers.
B. Give the digoxin with extra fluids to dilute the sodium level.
C. Withhold the dose and report the potassium level.
D. Withhold the daily dose until the following day.
The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hypokalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and report the potassium level. The physician may order the digoxin to be given once the potassium level has been treated and rises to within normal range.
Correct Answer: C
23. The nurse is caring for a patient newly diagnosed with heart failure. The patient is to receive a first dose of digoxin (Lanoxin) 0.125 mg IV push. Available is an ampule containing 0.25 mg/ml. How many milliliters should the nurse draw up to administer the dose?
A. 0.5 ml
B. 0.6 ml
C. 1.2 ml
D. 1.4 ml
Correct Answer: A
24. The nurse is caring for a patient admitted with pulmonary edema secondary to acute decompensated heart failure. During the morning assessment, the patient complains of yellow vision. Which of the following medications would most likely be causing this clinical manifestation related to toxicity?
A. Meperidine (Demerol)
B. Atenolol (Tenormin)
C. Cefotetan (Cefotan)
D. Digoxin (Lanoxin)
Blurred or yellow vision is a sign of digitalis toxicity. The nurse would then assess the patient for other manifestations, such as anorexia, nausea, vomiting, and cardiac dysrhythmias.
Correct Answer: D
25. The priority nursing assessment of a patient receiving IV nesiritide (Natrecor) to treat heart failure (HF) would be:
A. Urine output
B. Lung sounds
C. Blood pressure
D. Respiratory rate
Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.
Correct Answer: C
26. When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient's heart rate to be which of the following?
A. 60 beats per minute
B. 75 beats per minute
C. 100 beats per minute
D. 150 beats per minute
Since each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15 in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case 100).
Correct Answer: C
27. Which of the following statements best describes the electrical activity of the heart represented by measuring the PR interval on the ECG?
A. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers
B. The length of time it takes to depolarize the atrium
C. The length of time it takes for the electrical impulse to travel from the SA node to the AV node
D. The length of time it takes for the atria to depolarize and repolarize
The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers in order for synchronous atrial and ventricular contraction to occur. The P wave represents atrial contraction and the R wave is part of the QRS complex that represents ventricular contraction. Therefore when measuring the time from the beginning of the P wave to the beginning of the QRS (PR interval), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers.
Correct Answer: A
28. The nurse obtains a 6-second rhythm strip and charts the following analysis: Atrial rate 70, regularVentricular rate 40, regularNo relationship between P waves and QRS complexes; atria and ventricles beating independently of each otherQRS 0.04 sec Which of the following would be a correct interpretation of this rhythm strip?
A. Premature ventricular contractions
B. Sinus dysrhythmias
C. Third-degree heart block
D. Wenckebach phenomenon
Third-degree heart block represents a loss of communication between the atrium and ventricles. This is depicted on the rhythm strip as no relationship between the P waves, representing atrial contraction, and QRS complexes, representing ventricular contraction. The atrium are beating totally on their own at 70 beats per minute, whereas the ventricles are pacing themselves at 40 beats per minute.
Correct Answer: C
29. The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which of the following nursing interventions is most appropriate at this time?
A. Encouraging range-of-motion exercises of the involved arm
B. Applying wet-to-dry dressings every 4 hours to the insertion site
C. Assessing the incision for any redness, swelling, or discharge
D. Reinforcing the pressure dressing as needed
After pacemaker insertion, it is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement. The nonpressure dressing is kept dry until removed, usually 24 hours postoperative. It is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site.
Correct Answer: C
30. The nurse is caring for a patient whose rhythm oscillates between atrial fibrillation and sinus rhythm. The nurse will be monitoring the patient closely, knowing that the patient is at an increased risk of developing which of the following?
A. Hypertension
B. Atrial emboli
C. Phlebitis
D. Complete heart block
During atrial fibrillation, the blood in the atrium can stagnate and more easily form clots. When the patient then converts to a normal sinus rhythm, the atrium again contract normally and may push those clots into the main circulation, which may result in an embolic event, most commonly a stroke.
Correct Answer: B
31. The nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves; instead there are wavy lines between the QRS complexes. The QRS complexes measure 0.08 seconds (narrow), but they occur irregularly with a rate of 120 beats per minute. The nurse correctly interprets that this rhythm is which of the following?
A. Sinus tachycardia
B. Atrial fibrillation
C. Ventricular tachycardia
D. Ventricular fibrillation
Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atrium are not truly contracting, just fibrillating.
Correct Answer: B
32. While admitting a patient with pericarditis, the nurse will assess for which of the following symptoms of a serious complication of this disorder?
A. Widened pulse pressure
B. Prolonged PR intervals
C. Pulsus paradoxus
D. Clubbing of the fingers.
Pericarditis can lead to cardiac tamponade, an emergency situation. Pulsus paradoxus >10 mm Hg is a sign of cardiac tamponade that should be assessed at least every 4 hours in a patient with pericarditis.
Correct Answer: C
33. The nurse conducts a complete physical assessment on a patient admitted with infective endocarditis. Which of the following findings is significant?
A. Respiratory rate of 18
B. Heart rate of 94
C. Regurgitant murmur at the mitral valve area
D. Capillary refill time of 2 seconds
A regurgitant murmur would indicate valvular disease, which can be a complication of endocarditis. All the other findings are within normal limits
Correct Answer: C
34. When caring for a patient with myocarditis, the nurse identifies the priority nursing diagnosis of:
A. Knowledge deficit
B. Decreased cardiac output
C. Alteration in comfort: pain
D. Activity intolerance
Myocarditis results in cardiac dysfunction and has been linked to the development of dilated cardiomyopathy. Decreased cardiac output is an ongoing nursing diagnosis. Although all the nursing diagnoses identified in this question may be appropriate for a patient with myocarditis, according to the ABCs for prioritization, cardiovascular compromise is the priority.
Correct Answer: B
35. The nurse is caring for a patient with a diagnosis of DVT. The patient has an order to receive 30 mg enoxaparin (Lovenox). Which of the following injection sites should the nurse use to administer this medication safely?
A. Back of the arm, 2 inches away from a mole
B. Anterolateral thigh, with no scar tissue nearby
C. Abdomen, anterior-lateral aspect
D. Buttock, upper outer quadrant
Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a subcutaneous injection. The preferred injection site for this medication is the right and left anterolateral abdominal wall. All subcutaneous injections should be given away from scars, lesions, or moles.
Correct Answer: C
36. The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. The nurse should do which of the following to administer this medication correctly?
A. Pinch the skin between the thumb and forefinger before inserting the needle.
B. Remove the air bubble in the prefilled syringe.
C. Rub the injection site after administration to enhance absorption.
D. Aspirate before injection to prevent intravenous administration.
The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not aspirate nor rub the site after injection.
Correct Answer: A
37. The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which of the following medications?
A. Protamine sulfate
B. Heparin sodium
C. Vitamin K
D. Vitamin B12
Coumadin is an anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, Vitamin K is given as the antidote for warfarin (Coumadin).
Correct Answer: C
38. The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the Coumadin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed?
A. Excessive bleeding from incision or IV sites
B. Decreased cardiac output
C. Cerebral or pulmonary emboli
D. Increased blood pressure
Coumadin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could again form. If one or more detach from the atrial wall, they could travel as cerebral emboli from the left atrium, or pulmonary emboli from the right atrium.
Correct Answer: C
39. The nurse is reviewing the laboratory test results for a 68-year-old patient whose
warfarin (Coumadin) therapy was terminated during the preoperative period. The nurse concludes that the patient is in most stable condition for surgery after noting which of the following INR (international normalized ratio) results?
A. 2.7
B. 1.0
C. 3.4
D. 1.8.
The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. The larger the number, the greater is the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed.
Correct Answer: B
40. The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting which of the following during a routine shift assessment?
A. Generalized weakness and fatigue
B. Abdominal pain with decreased bowel sounds
C. Crackles bilaterally in the lung bases
D. Pain and swelling in lower extremity
Enoxaparin is a low-molecular-weight heparin used to prevent the development of deep vein thromboses in the postoperative period. Pain and swelling in the lower extremity can indicate development of deep vein thrombosis and therefore may signal ineffective medication therapy.
Correct Answer: D
41. The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K1 (Phytonadione). The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which of the following?
A. 2.2
B. 1.0
C. 1.6
D. 1.2
Phytonadione is the antidote to sodium warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Coumadin is an anticoagulant that impairs the ability of the blood to clot. Therefore it is necessary to give phytonadione before
surgery to reduce the risk of hemorrhage. The largest value of the INR indicates the greatest impairment of clotting ability, making 2.1 the correct selection.
Correct Answer: A
42. A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which of the following replies by the nurse is most appropriate?
A. “This medication is a nonopioid analgesic that will help take away any muscle aches due to positioning on the operating room table.”
B. “This medication will help lower your blood pressure to a safer level, which is very important after surgery.”
C. “This medication will help prevent formation of blood clots in your legs until your level of mobility increases.”
D. “This medication will help prevent respiratory problems after surgery, including pneumonia.”
Enoxaparin is an anticoagulant that is used to prevent DVTs postoperatively. All other explanations/choices do not describe the action/purpose of enoxaparin.
Correct Answer: C
43. The nurse is caring for a preoperative patient who has an order for vitamin K1 (Phytonadione) 10 mg by subcutaneous injection. The nurse should verify that which of the following laboratory studies is abnormal before administering the dose?
A. Partial thromboplastin time (PTT)
B. Prothrombin time (PT)
C. Hemoglobin (Hb)
D. Hematocrit (Hct)
Phytonadione counteracts hypoprothrombinemia and/or reverses the effects of sodium warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the prothrombin time (PT) or the international normalized ratio (INR) demonstrate the need for this medication.
Correct Answer: B
44. The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. The nurse should do which of the following to administer this medication correctly?
A. Spread the skin before inserting the needle.
B. Sit the patient at a 30-degree angle before administration.
C. Leave the air bubble in the prefilled syringe.
D. Use the back of the arm as the preferred site.
The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue.
Correct Answer: C
45. The nurse is caring for a patient immediately following a transesophageal echocardiogram (TEE). Which of the following nursing interventions is appropriate when assessing this patient? (Select all that apply.)
A. Assessing for return of gag reflex
B. Monitoring vital signs and oxygen saturation
C. Assessing groin for hematoma or bleeding
D. Assessing lower extremities for circulatory compromise
The patient undergoing a TEE has been given conscious sedation and has had the throat numbed with a local anesthetic spray, thus eliminating the gag reflex until the effects wear off. Therefore it is imperative that the nurse assess for gag reflex return before allowing the patient to eat or drink. Vital signs and O2 saturation are also important assessment parameters secondary to the use of sedation. A TEE does not involve invasive procedures of the circulatory blood vessels; therefore it is not necessary to monitor the patient's groin or lower extremities in relation to this procedure.
Correct Answer: A, B
46. When providing nutritional counseling for patients at risk for CAD, which of the following foods would the nurse encourage patients to include in their diet? (Select all that apply.)
A. Tuna fish
B. Tofu
C. Walnuts
D. Whole milk
Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.
Correct Answer: A, B, C
47. The nurse would assess a patient with complaints of chest pain for which of the following clinical manifestations associated with a myocardial infarction (MI)? (Select all that apply.)
A. Flushing
B. Diaphoresis
C. Nausea and vomiting
D. S3 or S4 heart sounds
During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing an increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) secondary to this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.
Correct Answer: B, C, D
48. A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which of the following nursing actions would be appropriate to alleviate this patient's anxiety? (Select all that apply.)
A. Administration of ordered morphine sulfate
B. Position patient on left side with head of bed flat
C. Instructing patient on the use of relaxation techniques
D. Use a calm, reassuring approach while talking to patient
Morphine sulfate reduces anxiety and may assist in reducing dyspnea. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety. The patient should be positioned in semi-Fowler's position to improve ventilation.
Correct Answer: A, C, D
49. When caring for a patient with infective endocarditis, the nurse will assess the patient for which of the following vascular manifestations? (Select all that apply.)
A. Osler’s nodes
B. Janeway’s lesions
C. Splinter hemorrhages
D. Erythema marginatum lesions
Osler's nodes, Janeway's lesions, and splinter hemorrhages are all vascular manifestations of infective endocarditis. Erythema marginatum lesions occur with acute rheumatic fever.
Correct Answer: A, B, C