Chapter 27 Nursing School Test Banks

 

1.

The nurse is caring for a patient who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what?

A)

Lipids and fibrous tissue

B)

White blood cells

C)

Lipoproteins

D)

High-density cholesterol

Ans:

A

Feedback:

As T-lymphocytes and monocytes infiltrate to ingest lipids on the arterial wall and then die, a fibrous tissue develops. This causes plaques to form on the inner lumen of arterial walls. These plaques do not consist of white cells, lipoproteins, or high-density cholesterol.

2.

A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that angina is most often attributable to what cause?

A)

Decreased cardiac output

B)

Decreased cardiac contractility

C)

Infarction of the myocardium

D)

Coronary arteriosclerosis

Ans:

D

Feedback:

In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.

3.

The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?

A)

Ineffective breathing pattern related to decreased cardiac output

B)

Anxiety related to fear of death

C)

Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)

D)

Impaired skin integrity related to CAD

Ans:

C

Feedback:

Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.

4.

The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patients symptoms are due to an MI, what will have happened to the myocardium?

A)

It may have developed an increased area of infarction during the time without treatment.

B)

It will probably not have more damage than if he came in immediately.

C)

It may be responsive to restoration of the area of dead cells with proper treatment.

D)

It has been irreparably damaged, so immediate treatment is no longer necessary.

Ans:

A

Feedback:

When the patient experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is initiated, the more likely the treatment will prevent or minimize myocardial tissue necrosis. Delays in treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be restored by any means.

5.

Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?

A)

The symptoms indicate angina and should be treated as such.

B)

The symptoms indicate a pulmonary etiology rather than a cardiac etiology.

C)

The symptoms indicate an acute coronary episode and should be treated as such.

D)

Treatment should be determined pending the results of an exercise stress test.

Ans:

C

Feedback:

Angina and MI have similar symptoms and are considered the same process, but are on different points along a continuum. That the patients symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.

6.

An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what?

A)

Brachial artery

B)

Brachial vein

C)

Femoral artery

D)

Greater saphenous vein

Ans:

D

Feedback:

The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.

7.

A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA. For what complication should the nurse most closely monitor the patient?

A)

Hyperlipidemia

B)

Bleeding at insertion site

C)

Left ventricular hypertrophy

D)

Congestive heart failure

Ans:

B

Feedback:

Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include hyperlipidemia, left ventricular hypertrophy, or congestive heart failure; each of these problems takes an extended time to develop and none is emergent.

8.

The nurse is caring for a patient who is scheduled for cardiac surgery. What should the nurse include in preoperative care?

A)

With the patient, clarify the surgical procedure that will be performed.

B)

Withhold the patients scheduled medications for at least 12 hours preoperatively.

C)

Inform the patient that health teaching will begin as soon as possible after surgery.

D)

Avoid discussing the patients fears as not to exacerbate them.

Ans:

A

Feedback:

Preoperatively, it is necessary to evaluate the patients understanding of the surgical procedure, informed consent, and adherence to treatment protocols. Teaching would begin on admission or even prior to admission. The physician would write orders to alter the patients medication regimen if necessary; this will vary from patient to patient. Fears should be addressed directly and empathically.

9.

The OR nurse is explaining to a patient that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe?

A)

Coronary artery bypass graft (CABG)

B)

Percutaneous transluminal coronary angioplasty (PTCA)

C)

Atherectomy

D)

Cardiopulmonary bypass

Ans:

D

Feedback:

Cardiopulmonary bypass is often used to circulate and oxygenate blood mechanically while bypassing the heart and lungs. PTCA, atherectomy, and CABG are all surgical procedures, none of which achieves the two goals listed.

10.

The nurse has just admitted a 66-year-old patient for cardiac surgery. The patient tearfully admits to the nurse that she is afraid of dying while undergoing the surgery. What is the nurses best response?

A)

Explore the factors underlying the patients anxiety.

B)

Teach the patient guided imagery techniques.

C)

Obtain an order for a PRN benzodiazepine.

D)

Describe the procedure in greater detail.

Ans:

A

Feedback:

An assessment of anxiety levels is required in the patient to assist the patient in identifying fears and developing coping mechanisms for those fears. The nurse must further assess and explore the patients anxiety before providing interventions such as education or medications.

11.

A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects?

A)

Nervousness or paresthesia

B)

Throbbing headache or dizziness

C)

Drowsiness or blurred vision

D)

Tinnitus or diplopia

Ans:

B

Feedback:

Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.

12.

The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors would the nurse list that can be controlled or modified?

A)

Gender, obesity, family history, and smoking

B)

Inactivity, stress, gender, and smoking

C)

Obesity, inactivity, diet, and smoking

D)

Stress, family history, and obesity

Ans:

C

Feedback:

The risk factors for CAD that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that cannot be controlled.

13.

A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU?

A)

Begin ECG monitoring.

B)

Obtain information about family history of heart disease.

C)

Auscultate lung fields.

D)

Determine if the patient smokes.

Ans:

A

Feedback:

The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the patient smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.

14.

The public health nurse is participating in a health fair and interviews a patient with a history of hypertension, who is currently smoking one pack of cigarettes per day. She denies any of the most common manifestations of CAD. Based on these data, the nurse would expect the focuses of CAD treatment most likely to be which of the following?

A)

Drug therapy and smoking cessation

B)

Diet and drug therapy

C)

Diet therapy only

D)

Diet therapy and smoking cessation

Ans:

D

Feedback:

Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostics findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms.

15.

The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs?

A)

The patient experiences chest pain, palpitations, or dyspnea.

B)

The patient experiences a noticeable increase in heart rate during activity.

C)

The patients oxygen saturation level drops below 96%.

D)

The patients respiratory rate exceeds 30 breaths/min.

Ans:

A

Feedback:

Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most patients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.

16.

A patient with cardiovascular disease is being treated with amlodipine (Norvasc), a calcium channel blocking agent. The therapeutic effects of calcium channel blockers include which of the following?

A)

Reducing the hearts workload by decreasing heart rate and myocardial contraction

B)

Preventing platelet aggregation and subsequent thrombosis

C)

Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart

D)

Increasing the efficiency of myocardial oxygen consumption, thus decreasing ischemia and relieving pain

Ans:

A

Feedback:

Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are administered to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.

17.

The nurse is providing care for a patient with high cholesterol and triglyceride values. In teaching the patient about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following?

A)

High HDL values and high triglyceride values

B)

Absence of detectable total cholesterol levels

C)

Elevated blood lipids, fasting glucose less than 100

D)

Low LDL values and high HDL values

Ans:

D

Feedback:

The desired goal for cholesterol readings is for a patient to have low LDL and high HDL values. LDL exerts a harmful effect on the coronary vasculature because the small LDL particles can be easily transported into the vessel lining. In contrast, HDL promotes the use of total cholesterol by transporting LDL to the liver, where it is excreted. Elevated triglycerides are also a major risk factor for cardiovascular disease. A goal is also to keep triglyceride levels less than 150 mg/dL. All individuals possess detectable levels of total cholesterol.

18.

When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena?

A)

Exercise increases the hearts oxygen demands.

B)

Exercise causes vasoconstriction of the coronary arteries.

C)

Exercise shunts blood flow from the heart to the mesenteric area.

D)

Exercise increases the metabolism of cardiac medications.

Ans:

A

Feedback:

Physical exertion increases the myocardial oxygen demand. If the patient has arteriosclerosis of the coronary arteries, then blood supply is diminished to the myocardium. Exercise does not cause vasoconstriction or interfere with drug metabolism. Exercise does not shunt blood flow away from the heart.

19.

The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?

A)

P wave inversion

B)

T wave inversion

C)

Q wave changes with no change in ST or T wave

D)

P wave enlargement

Ans:

B

Feedback:

T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.

20.

An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions?

A)

Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories

B)

Morphine sulphate, oxygen, and bed rest

C)

Oxygen and beta-adrenergic blockers

D)

Bed rest, albuterol nebulizer treatments, and oxygen

Ans:

B

Feedback:

The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine sulphate reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.

21.

The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurses most recent assessment reveals that the patients left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurses best response?

A)

Document this expected assessment finding during the initial postoperative period.

B)

Reposition the patient with his left leg in a dependent position.

C)

Inform the patients physician of this assessment finding.

D)

Administer an ordered dose of subcutaneous heparin.

Ans:

C

Feedback:

If a pulse is absent in any extremity, the cause may be prior catheterization of that extremity, chronic peripheral vascular disease, or a thromboembolic obstruction. The nurse immediately reports newly identified absence of any pulse.

22.

In preparation for cardiac surgery, a patient was taught about measures to prevent venous thromboembolism. What statement indicates that the patient clearly understood this education?

A)

Ill try to stay in bed for the first few days to allow myself to heal.

B)

Ill make sure that I dont cross my legs when Im resting in bed.

C)

Ill keep pillows under my knees to help my blood circulate better.

D)

Ill put on those compression stockings if I get pain in my calves.

Ans:

B

Feedback:

To prevent venous thromboembolism, patients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge.

23.

An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients? Select all that apply.

A)

Shortness of breath

B)

Chest pain

C)

Anxiety

D)

Numbness

E)

Weakness

Ans:

D, E

Feedback:

Although these symptoms are not wholly absent in men, many women have been found to have atypical symptoms of MI, including indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among patients of all ages and genders.

24.

When assessing a patient diagnosed with angina pectoris it is most important for the nurse to gather what information?

A)

The patients activities limitations and level of consciousness after the attacks

B)

The patients symptoms and the activities that precipitate attacks

C)

The patients understanding of the pathology of angina

D)

The patients coping strategies surrounding the attacks

Ans:

B

Feedback:

The nurse must gather information about the patients symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. The patients coping, understanding of the disease, and status following attacks are all important to know, but causative factors are a primary focus of the assessment interview.

25.

You are writing a care plan for a patient who has been diagnosed with angina pectoris. The patient describes herself as being distressed and shocked by her new diagnosis. What nursing diagnosis is most clearly suggested by the womans statement?

A)

Spiritual distress related to change in health status

B)

Acute confusion related to prognosis for recovery

C)

Anxiety related to cardiac symptoms

D)

Deficient knowledge related to treatment of angina pectoris

Ans:

C

Feedback:

Although further assessment is warranted, it is not unlikely that the patient is experiencing anxiety. In patients with CAD, this often relates to the threat of sudden death. There is no evidence of confusion (i.e., delirium or dementia) and there may or may not be a spiritual element to her concerns. Similarly, it is not clear that a lack of knowledge or information is the root of her anxiety.

26.

The nurse is caring for patient who tells the nurse that he has an angina attack beginning. What is the nurses most appropriate initial action?

A)

Have the patient sit down and put his head between his knees.

B)

Have the patient perform pursed-lip breathing.

C)

Have the patient stand still and bend over at the waist.

D)

Place the patient on bed rest in a semi-Fowlers position.

Ans:

D

Feedback:

When a patient experiences angina, the patient is directed to stop all activities and sit or rest in bed in a semi-Fowlers position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip breathing and standing will not reduce workload to the same extent. No need to have the patient put his head between his legs because cerebral perfusion is not lacking.

27.

A patient presents to the ED in distress and complaining of crushing chest pain. What is the nurses priority for assessment?

A)

Prompt initiation of an ECG

B)

Auscultation of the patients point of maximal impulse (PMI)

C)

Rapid assessment of the patients peripheral pulses

D)

Palpation of the patients cardiac apex

Ans:

A

Feedback:

The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. Each of the other listed assessments is valid, but ECG monitoring is the most time dependent priority.

28.

The ED nurse is caring for a patient with a suspected MI. What drug should the nurse anticipate administering to this patient?

A)

Oxycodone

B)

Warfarin

C)

Morphine

D)

Acetaminophen

Ans:

C

Feedback:

The patient with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta- blocker, and other medications, as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are not typically used.

29.

The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply.

A)

Dyspnea

B)

Unusual fatigue

C)

Hypotension

D)

Syncope

E)

Peripheral cyanosis

Ans:

A, B, D

Feedback:

Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS.

30.

The nurse is creating a plan of care for a patient with acute coronary syndrome. What nursing action should be included in the patients care plan?

A)

Facilitate daily arterial blood gas (ABG) sampling.

B)

Administer supplementary oxygen, as needed.

C)

Have patient maintain supine positioning when in bed.

D)

Perform chest physiotherapy, as indicated.

Ans:

B

Feedback:

Oxygen should be administered along with medication therapy to assist with symptom relief. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea. ABGs are diagnostic, not therapeutic, and they are rarely needed on a daily basis. Chest physiotherapy is not used in the treatment of ACS.

31.

The nurse is participating in the care conference for a patient with ACS. What goal should guide the care teams selection of assessments, interventions, and treatments?

A)

Maximizing cardiac output while minimizing heart rate

B)

Decreasing energy expenditure of the myocardium

C)

Balancing myocardial oxygen supply with demand

D)

Increasing the size of the myocardial muscle

Ans:

C

Feedback:

Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the patient with ACS. Treatment is not aimed directly at minimizing heart rate because some patients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardiums energy expenditure is often beneficial, but this must be balanced with productivity.

32.

The nurse working on the coronary care unit is caring for a patient with ACS. How can the nurse best meet the patients psychosocial needs?

A)

Reinforce the fact that treatment will be successful.

B)

Facilitate a referral to a chaplain or spiritual leader.

C)

Increase the patients participation in rehabilitation activities.

D)

Directly address the patients anxieties and fears.

Ans:

D

Feedback:

Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Referrals to spiritual care may or may not be appropriate, and this does not relieve the nurse of responsibility for addressing the patients psychosocial needs. Treatment is not always successful, and false hope should never be fostered. Participation in rehabilitation may alleviate anxiety for some patients, but it may exacerbate it for others.

33.

The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure?

A)

Increase in the size of the arterys lumen

B)

Decrease in arterial blood flow in relation to venous flow

C)

Increase in the patients resting heart rate

D)

Increase in the patients level of consciousness (LOC)

Ans:

A

Feedback:

PTCA is used to open blocked coronary vessels and resolve ischemia. The procedure may result in beneficial changes to the patients LOC or heart rate, but these are not the overarching goals of PTCA. Increased arterial flow is the focus of the procedures.

34.

A nurse has taken on the care of a patient who had a coronary artery stent placed yesterday. When reviewing the patients daily medication administration record, the nurse should anticipate administering what drug?

A)

Ibuprofen

B)

Clopidogrel

C)

Dipyridamole

D)

Acetaminophen

Ans:

B

Feedback:

Because of the risk of thrombus formation within the stent, the patient receives antiplatelet medications, usually aspirin and clopidogrel. Ibuprofen and acetaminophen are not antiplatelet drugs. Dipyridamole is not the drug of choice following stent placement.

35.

A nurse is working with a patient who has been scheduled for a percutaneous coronary intervention (PCI) later in the week. What anticipatory guidance should the nurse provide to the patient?

A)

He will remain on bed rest for 48 to 72 hours after the procedure.

B)

He will be given vitamin K infusions to prevent bleeding following PCI.

C)

A sheath will be placed over the insertion site after the procedure is finished.

D)

The procedure will likely be repeated in 6 to 8 weeks to ensure success.

Ans:

C

Feedback:

A sheath is placed over the PCI access site and kept in place until adequate coagulation is achieved. Patients resume activity a few hours after PCI and repeated treatments may or may not be necessary. Anticoagulants, not vitamin K, are administered during PCI.

36.

Preoperative education is an important part of the nursing care of patients having coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse would be sure to include education about which subject?

A)

Symptoms of hypovolemia

B)

Symptoms of low blood pressure

C)

Complications requiring graft removal

D)

Intubation and mechanical ventilation

Ans:

D

Feedback:

Most patients remain intubated and on mechanical ventilation for several hours after surgery. It is important that patients realize that this will prevent them from talking, and the nurse should reassure them that the staff will be able to assist them with other means of communication. Teaching would generally not include symptoms of low blood pressure or hypovolemia, as these are not applicable to most patients. Teaching would also generally not include rare complications that would require graft removal.

37.

A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in her femoral region. What is the nurses most appropriate action?

A)

Call for assistance and initiate cardiopulmonary resuscitation.

B)

Reposition the patients leg in a nondependent position.

C)

Promptly remove the femoral sheath.

D)

Call for help and apply pressure to the access site.

Ans:

D

Feedback:

The femoral sheath produces pressure on the access site. Pressure will temporarily reduce bleeding and allow for subsequent interventions. Removing the sheath would exacerbate bleeding and repositioning would not halt it. CPR is not indicated unless there is evidence of respiratory or cardiac arrest.

38.

The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply.

A)

Abrupt closure of the coronary artery

B)

Venous insufficiency

C)

Bleeding at the insertion site

D)

Retroperitoneal bleeding

E)

Arterial occlusion

Ans:

A, C, D, E

Feedback:

Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute renal failure. Venous insufficiency is not a postprocedure complication of a PTCA.

39.

A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurses most appropriate action?

A)

Document the patients low urine output and monitor closely for the next several hours.

B)

Contact the dietitian and suggest the need for increased oral fluid intake.

C)

Contact the patients physician and suggest assessment of fluid balance and renal function.

D)

Increase the infusion rate of the patients IV fluid to prompt an increase in renal function.

Ans:

C

Feedback:

Nursing management includes accurate measurement of urine output. An output of less than 1 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.

40.

A patient is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk?

A)

Administration of bronchodilators by nebulizer

B)

Administration of inhaled corticosteroids by metered dose inhaler (MDI)

C)

Patients consistent performance of deep breathing and coughing exercises

D)

Patients active participation in the cardiac rehabilitation program

Ans:

C

Feedback:

Clearance of pulmonary secretions is accomplished by frequent repositioning of the patient, suctioning, and chest physical therapy, as well as educating and encouraging the patient to breathe deeply and cough. Medications are not normally used to achieve this goal. Rehabilitation is important, but will not necessarily aid the mobilization of respiratory secretions.

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