NUR 417 Exam 1 (Module 1-4) | Answered with Rationales

NUR 417 Exam 1 (Module 1-4) | Answered with Rationales An older adult patient who has just arrived in the emergency department has a pulse deficit of 46 beats. Which intervention would the nurse anticipate for this pa ...

NUR 417 Exam 1 (Module 1-4) | Answered with Rationales An older adult patient who has just arrived in the emergency department has a pulse deficit of 46 beats. Which intervention would the nurse anticipate for this patient? 1. Cardiac catheterization 2. Hourly blood pressure checks 3. Electrocardiographic monitoring 4. Emergent synchronized cardioversion Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit. How would the nurse listen to auscultate for S3 or S4 gallops in the mitral area? 1. Use the diaphragm of the stethoscope with the patient lying flat. 2. Use the bell of the stethoscope with the patient in the left lateral position. 3. Use the diaphragm of the stethoscope with the patient in a supine position. 4. Use the bell of the stethoscope with the patient sitting and leaning forward. Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher pitched sounds such as S1 and S2. A patient is being treated for heart failure. Which laboratory test result will the nurse review to determine the effects of the treatment? 1. Troponin 2. Homocysteine (Hcy) 3. Low-density lipoprotein (LDL) 4. B-type natriuretic peptide (BNP) Levels of BNP are a marker for heart failure. The other laboratory results would assess for myocardial infarction (troponin) or the risk for coronary artery disease (Hcy and LDL). A patient is scheduled for a cardiac catheterization with coronary angiography. What information would the nurse provide before the procedure? 1. It will be important not to move at all during the procedure. 2. A flushed feeling is common when the contrast dye is injected. 3. Monitored anesthesia care will be provided during the procedure. 4. Arterial pressure monitoring will be needed for 24 hours after the test. A sensation of warmth or flushing is common when the 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 anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths. A patient will be evaluated for rhythm disturbances with a Holter monitor. Which instruction would the nurse provide? 1. Connect the recorder to a computer once daily. 2. Exercise more than usual while the monitor is in place. 3. Remove the electrodes when taking a shower or tub bath. 4. Keep a diary of daily activities while the monitor is worn. The patient is taught to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient's rhythm until the end of the testing, when it is removed and the data are analyzed. How would the nurse document a loud humming sound auscultated over the patient's abdominal aorta? 1. Thrill 2. Bruit 3. Murmur 4. Normal finding A bruit is the sound created by turbulent blood flow in an artery. Auscultating a bruit in an artery is not normal and indicates pathology. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." Which patient's status would the nurse report to the health care provider? 1. Postoperative patient with a BP of 116/42 mm Hg. 2. Newly admitted patient with a BP of 150/87 mm Hg. 3. Patient with left ventricular failure who has a BP of 110/70 mm Hg. 4. Patient with a myocardial infarction who has a BP of 140/86 mm Hg. The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient is 67. The MAP in the other three patients is higher than 70 mm Hg. The nurse is admitting a patient for a cardiac catheterization and coronary angiogram. Which information is important for the nurse to communicate to the health care provider before the test? 1. The patient's pedal pulses are +1. 2. The patient is allergic to contrast dye. 3. The patient had a heart attack 1 year ago. 4. The patient has not eaten anything today. Patients who have allergies to contrast dye will require treatment with medications, such as corticosteroids and antihistamines before the angiogram. The other information may be communicated to the health care provider but will not require a change in the usual pre-cardiac catheterization orders or medications. The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which laboratory result is most important to communicate rapidly to the health care provider? 1. High troponin I level 2. Increased triglyceride level 3. Very low homocysteine level 4. Elevated C-reactive protein level The elevation in troponin I indicates that the patient has had an acute myocardial infarction. Further assessment and interventions are indicated. The other laboratory results indicate increased risk for coronary artery disease but are not associated with acute cardiac problems that need immediate intervention. Which hemodynamic parameter most directly reflects the effectiveness of drugs given to reduce a patient's left ventricular afterload? 1. Cardiac output (CO) 2. Systemic vascular resistance (SVR) 3. Pulmonary vascular resistance (PVR) 4. Pulmonary artery wedge pressure (PAWP) SVR reflects the resistance to left ventricular ejection, or afterload. Other parameters may be monitored but do not reflect left-sided afterload as directly. After surgery, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action would the nurse take? 1. Administer IV diuretic medications. 2. Increase the IV fluid infusion per protocol. 3. Increase the infusion rate of IV vasodilators. 4. Elevate the head of the patient's bed to 45 degrees. A low CVP indicates decreased preload from hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head or increasing vasodilators may decrease cerebral perfusion. Which parameter will the nurse use to evaluate changes in a patient's right ventricular afterload? 1. Central venous pressure (CVP) 2. Systemic vascular resistance (SVR) 3. Pulmonary vascular resistance (PVR) 4. Pulmonary artery wedge pressure (PAWP) PVR is a measure of right ventricular afterload, which is elevated in conditions such as pulmonary hypertension The other parameters do not directly assess for right ventricular afterload. A patient requires arterial pressure monitoring. Which action would the nurse plan to take? 1. Balance and calibrate the monitoring equipment every 2 hours. 2. Position the zero-reference stopcock line level with the phlebostatic axis. 3. Disconnect the low pressure alarm to avoid disturbing the patient's sleep. 4. Ensure that the patient is supine with the head of the bed flat for all readings. For accurate measurement of pressures, the zero-reference level would be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment every 2 hours. Accurate hemodynamic readings are possible with the patient's head raised to 45 degrees or in the prone position. Alarms should be activated; if the pressure in the line falls (e.g., when the line is disconnected), the low-pressure alarm sounds immediately and notifies staff to promptly correct the problem. Which measurement would be the most sensitive indicator of cardiac function? 1. Central venous pressure (CVP) 2. Systemic vascular resistance (SVR) 3. Pulmonary vascular resistance (PVR) 4. Pulmonary artery wedge pressure (PAWP) PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive indicator of cardiac function. The other values would also provide useful information, but the most definitive measurement of changes in cardiac function is the PAWP. Which action would the nurse take first when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery? 1. Observe for dysrhythmias. 2. Fast flush the arterial line. 3. Check the left hand for pallor. 4. Re-zero the monitoring equipment. The low pressure alarm indicates a drop in the patient's blood pressure, which may be caused by dysrhythmias or line disconnection. There is no indication to re-zero the equipment. Pallor of the left hand would be caused by occlusion of the radial artery by the arterial catheter. Flushing the line would be useful if there is a dampened waveform. Which action would the nurse take when preparing to assist with the insertion of a pulmonary artery catheter? 1. Determine if the cardiac troponin level is elevated. 2. Place the patient on NPO status before the procedure. 3. Auscultate heart sounds before and during catheter insertion. 4. Assure that the cardiac monitor is visible during the procedure. Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter insertion. The nurse is assisting with the placement of a pulmonary artery (PA) catheter. What would the nurse expect to see on the monitor during the procedure as an indication that the catheter with inflated balloon is placed correctly? 1. PA pressure waveform 2. PA wedge pressure (PAWP) waveform 3. Tracing of the systemic arterial pressure 4. Tracing of the systemic vascular resistance The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP readings are available. After insertion, the balloon is deflated, and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line, and the systemic vascular resistance is a calculated value, not a waveform. Which finding by the nurse caring for a patient with a right radial arterial line indicates a need for the nurse to take action? 1. The left hand feels warmer than the right hand. 2. The mean arterial pressure (MAP) is 77 mm Hg. 3. The system is delivering 3 mL of flush solution per hour. 4. The flush bag and tubing were changed 2 days previously. The cooler temperature of the right hand suggests that blood flow to the right hand may be impaired; further assessment may lead to plans for removal of the radial catheter to avoid permanent injury to the right hand. The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 70-105 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hr of flush solution. The nurse is caring for a patient who has an arterial catheter in the left radial artery for arterial pressure-based cardiac output (APCO) monitoring. Which information obtained by the nurse requires a report to the health care provider? 1. The patient has a positive Allen test result. 2. There is redness at the catheter insertion site. 3. The mean arterial pressure (MAP) is 86 mm Hg. 4. The dicrotic notch is visible in the arterial waveform. Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test result indicates normal ulnar artery perfusion. A MAP of 86 mm Hg is normal, and the dicrotic notch is normally present on the arterial waveform. A patient with respiratory failure has arterial pressure-based cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required? 1. The arterial pressure is 90/46. 2. The heart rate is 58 beats/min. 3. The stroke volume is increased. 4. The stroke volume variation is 12%. The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and (potentially) cardiac output. The other assessment data would not be a direct result of PEEP and mechanical ventilation. A patient's vital signs are pulse 90, respirations 24, and BP 128/64 mm Hg, and cardiac output is 4.7 L/min. What is the patient's stroke volume in mL. (Round to the nearest whole number.) 52 Stroke volume = Cardiac output/heart rate 52 mL = (4.7 L x 1000 mL/L)/90. An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which data would indicate to the nurse that the goals of IABP treatment are being met? 1. Urine output of 25 mL/hr 2. Heart rate of 110 beats/min 3. Cardiac output (CO) of 5 L/min 4. Stroke volume (SV) of 40 mL/beat A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock. The nurse is caring for a patient who has an intra-aortic balloon pump in place. Which action would the nurse include in the plan of care? 1. Avoid the use of anticoagulant medications. 2. Monitor the patient's urinary output every hour. 3. Provide passive range of motion for all extremities. 4. Position the patient supine with head flat at all times. Monitoring urine output will help determine whether the patient's cardiac output has improved. It also will help assess for balloon displacement blocking the renal arteries. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon. While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. Which action would the nurse include in the plan of care for this patient? 1. Preparing the patient for a permanent VAD 2. Teaching the patient the reason for bed rest 3. Monitoring the incision for signs of infection 4. Administering immunosuppressants medications The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs can have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices such as the VAD. A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and dextrose from a bag that was hung with new tubing and filter 24 hours ago. The nurse observes that about 50 mL remain in the PN container. Which action would the nurse take? 1. Add a new container of PN using the current tubing and filter. 2. Hang a new container of PN and change the IV tubing and filter. 3. Infuse the remaining 50 mL and then hang a new container of PN. 4. Ask the health care provider to clarify the written PN prescription. All PN solutions and tubings are changed at 24 hours. Infusion of the additional 50 mL will increase patient risk for infection. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes. A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. Which action would the nurse take? 1. Obtain a venous blood glucose specimen. 2. Slow the infusion rate of the PN infusion. 3. Recheck the blood glucose level in 4 to 6 hours. 4. Contact the health care provider for infusion rate changes. Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring. Because the glucose elevation is small and expected, infusion rate changes are not needed. There is no need to obtain a venous specimen for comparison. Slowing the rate of the infusion is beyond the nurse's scope of practice and will decrease the patient's nutritional intake. After abdominal surgery, a patient with protein-calorie malnutrition is receiving parenteral nutrition (PN). Which data is the best indicator that the patient is receiving adequate nutrition? 1. Serum albumin level is 3.5 mg/dL. 2. Fluid intake and output are balanced. 3. Surgical incision is healing normally. 4. Blood glucose is less than 110 mg/dL. Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient's nutrition is adequate. The intake and output will be monitored, but do not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect adequate caloric intake, which is also important for the patient. A patient's peripheral parenteral nutrition (PN) bag is nearly empty, and a new PN bag has not arrived yet from the pharmacy. Which action would the nurse take? 1. Monitor the patient's capillary blood glucose every 6 hours. 2. Infuse 5% dextrose in water until a new PN bag is delivered. 3. Decrease the PN infusion rate to 10 mL/hr until a new bag arrives. 4. Flush the peripheral line with saline until a new PN bag is available. To prevent hypoglycemia, the nurse should infuse a 5% dextrose solution until the next peripheral PN bag can be started. Decreasing the rate of the ordered PN infusion is beyond the nurse's scope of practice. Flushing the line and then waiting for the next bag may lead to hypoglycemia. Monitoring the capillary blood glucose every 6 hours would not identify hypoglycemia while awaiting the new PN bag. An unresponsive patient who has type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemia syndrome (HHS). Which action would the nurse anticipate taking? 1. Giving 50% dextrose 2. Inserting an IV catheter 3. Initiating O2 by nasal cannula 4. Administering glargine (Lantus) insulin HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires O2. Concentrated dextrose solutions will increase the patient's glucose and would be contraindicated. A 26-yr-old female who has type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and reports a glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. Which action would the nurse advise the patient to take? 1. Use only the lispro insulin until the symptoms are resolved. 2. Limit intake of calories until the glucose is less than 120 mg/dL. 3. Monitor blood glucose every 4 hours and contact the clinic if it rises. 4. Decrease carbohydrates until glycosylated hemoglobin is less than 7%. Infection and other stressors increase glucose levels and the patient will need to test glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin testing is not used to evaluate short-term alterations in glucose. The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6 AM glucose is 230 mg/dL. Which action would the nurse teach the patient to take? 1. Check the glucose during the night. 2. Avoid snacking right before bedtime. 3. Increase the rapid-acting insulin dose. 4. Administer a larger dose of long-acting insulin. If the Somogyi effect is causing the patient's increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night. A 27-yr-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider would the nurse implement first? 1. Place the patient on a cardiac monitor. 2. Administer IV potassium supplements. 3. Ask the patient about home insulin doses. 4. Start an insulin infusion at 0.1 units/kg/hr. Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse would initiate cardiac monitoring before infusion of potassium. Insulin would not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Discussion of home insulin and possible causes can wait until the patient is stabilized. A patient with diabetic ketoacidosis is brought to the emergency department. Which prescribed action would the nurse implement first? 1. Infuse 1 L of normal saline rapidly. 2. Give sodium bicarbonate 50 mEq IV push. 3. Administer regular insulin 10 U by IV push. 4. Start a regular insulin infusion at 0.1 units/kg/hr. The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. Insulin can be given after the infusion of normal saline is initiated. Sodium bicarbonate may be given for severe acidosis (pH <7.0) after fluids are initiated. A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action would the nurse take first?