Chapter 37: Nursing Management: Inflammatory and Structural Heart Disorders Nursing School Test Banks

Chapter 37: Nursing Management: Inflammatory and Structural Heart Disorders

Test Bank

MULTIPLE CHOICE

1. The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate?

a.

Do you have a history of a heart attack?

b.

Is there a family history of endocarditis?

c.

Have you had any recent immunizations?

d.

Have you had dental work done recently?

ANS: D

Dental procedures place the patient with a prosthetic mitral valve at risk for infective endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE.

DIF: Cognitive Level: Apply (application) REF: 812

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. During the assessment of a 25-year-old patient with infective endocarditis (IE), the nurse would expect to find

a.

substernal chest pressure.

b.

a new regurgitant murmur.

c.

a pruritic rash on the chest.

d.

involuntary muscle movement.

ANS: B

New regurgitant murmurs occur in IE because vegetations on the valves prevent valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever.

DIF: Cognitive Level: Understand (comprehension) REF: 811 | 821

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE) based on which assessment finding(s)?

a.

Fever, chills, and diaphoresis

b.

Urine output less than 30 mL/hr

c.

Petechiae on the inside of the mouth and conjunctiva

d.

Increase in heart rate of 15 beats/minute with walking

ANS: B

Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE, but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise.

DIF: Cognitive Level: Apply (application) REF: 812

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

4. When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is a priority for the nurse to include?

a.

Monitor labs for streptococcal antibodies.

b.

Arrange for placement of a long-term IV catheter.

c.

Teach the importance of completing all oral antibiotics.

d.

Encourage the patient to begin regular aerobic exercise.

ANS: B

Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy.

DIF: Cognitive Level: Apply (application) REF: 814

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

5. A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to teach the patient about the purpose of

a.

echocardiography.

b.

daily blood cultures.

c.

cardiac catheterization.

d.

24-hour Holter monitor.

ANS: A

Echocardiograms are useful in detecting the presence of the pericardial effusions associated with pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac catheterization and 24-hour Holter monitor is not a diagnostic procedure for pericarditis.

DIF: Cognitive Level: Apply (application) REF: 816

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

6. To assess the patient with pericarditis for evidence of a pericardial friction rub, the nurse should

a.

listen for a rumbling, low-pitched, systolic murmur over the left anterior chest.

b.

auscultate by placing the diaphragm of the stethoscope on the lower left sternal border.

c.

ask the patient to cough during auscultation to distinguish the sound from a pleural friction rub.

d.

feel the precordial area with the palm of the hand to detect vibrations with cardiac contraction.

ANS: B

Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. The nurse should ask the patient to hold his or her breath during auscultation to distinguish the sounds from a pleural friction rub. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation.

DIF: Cognitive Level: Understand (comprehension) REF: 815

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, the nurse should

a.

note when Korotkoff sounds are auscultated during both inspiration and expiration.

b.

subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).

c.

check the electrocardiogram (ECG) for variations in rate during the respiratory cycle.

d.

listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.

ANS: A

Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.

DIF: Cognitive Level: Understand (comprehension) REF: 816

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. The priority intervention by the nurse for this problem is to

a.

teach the patient to take deep, slow breaths to control the pain.

b.

force fluids to 3000 mL/day to decrease fever and inflammation.

c.

remind the patient to request opioid pain medication every 4 hours.

d.

place the patient in Fowlers position, leaning forward on the overbed table.

ANS: D

Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep breaths will tend to increase pericardial pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually ordered PRN. The patient would receive scheduled doses of a nonsteroidal antiinflammatory drug (NSAID).

DIF: Cognitive Level: Apply (application) REF: 817

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

9. The nurse is admitting a patient with possible rheumatic fever. Which question on the admission health history will be most pertinent to ask?

a.

Do you use any illegal IV drugs?

b.

Have you had a recent sore throat?

c.

Have you injured your chest in the last few weeks?

d.

Do you have a family history of congenital heart disease?

ANS: B

Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection. Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for rheumatic fever, and would not be as pertinent when admitting the patient. Family history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.

DIF: Cognitive Level: Apply (application) REF: 819

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. Based on these findings, which nursing diagnosis would be most appropriate?

a.

Pain related to permanent joint fixation

b.

Activity intolerance related to arthralgia

c.

Risk for infection related to open skin lesions

d.

Risk for impaired skin integrity related to pruritus

ANS: B

The patients joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic fever are not open or pruritic. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes.

DIF: Cognitive Level: Apply (application) REF: 819-820

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

11. The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge regarding long-term management of rheumatic fever when a 30-year-old recovering from rheumatic fever without carditis says which of the following?

a.

I will need prophylactic antibiotic therapy for 5 years.

b.

I will need to take aspirin or ibuprofen (Motrin) to relieve my joint pain.

c.

I will call the doctor if I develop excessive fatigue or difficulty breathing.

d.

I will be immune to further episodes of rheumatic fever after this infection.

ANS: D

Patients with a history of rheumatic fever are more susceptible to a second episode. Patients with rheumatic fever without carditis require prophylaxis until age 20 and for a minimum of 5 years. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance.

DIF: Cognitive Level: Apply (application) REF: 820

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

12. When developing a community health program to decrease the incidence of rheumatic fever, which action would be most important for the community health nurse to include?

a.

Vaccinate high-risk groups in the community with streptococcal vaccine.

b.

Teach community members to seek treatment for streptococcal pharyngitis.

c.

Teach about the importance of monitoring temperature when sore throats occur.

d.

Teach about prophylactic antibiotics to those with a family history of rheumatic fever.

ANS: B

The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring temperature will not decrease the incidence of rheumatic fever.

DIF: Cognitive Level: Apply (application) REF: 820

TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

13. When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for

a.

diastolic murmur.

b.

peripheral edema.

c.

shortness of breath on exertion.

d.

right upper quadrant tenderness.

ANS: C

The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease but are not indicators of possible hypoxemia.

DIF: Cognitive Level: Apply (application) REF: 821

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

14. A 21-year-old woman is scheduled for percutaneous transluminal balloon valvuloplasty to treat mitral stenosis. Which information should the nurse include when explaining the advantages of valvuloplasty over valve replacement to the patient?

a.

Biologic valves will require immunosuppressive drugs after surgery.

b.

Mechanical mitral valves need to be replaced sooner than biologic valves.

c.

Lifelong anticoagulant therapy will be needed after mechanical valve replacement.

d.

Ongoing cardiac care by a health care provider is not necessary after valvuloplasty.

ANS: C

Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict decisions about career and childbearing in this patient. Mechanical valves are durable and last longer than biologic valves. All valve repair procedures are palliative, not curative, and require lifelong health care. Biologic valves do not activate the immune system, and immunosuppressive therapy is not needed.

DIF: Cognitive Level: Apply (application) REF: 824-825

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. While caring for a 23-year-old patient with mitral valve prolapse (MVP) without valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient states that it will be necessary to

a.

take antibiotics before any dental appointments.

b.

limit physical activity to avoid stressing the heart.

c.

take an aspirin a day to prevent clots from forming on the valve.

d.

avoid use of over-the-counter (OTC) medications that contain stimulant drugs.

ANS: D

Use of stimulant medications should be avoided by patients with MVP because these may exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient.

DIF: Cognitive Level: Apply (application) REF: 822

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

16. While caring for a patient with aortic stenosis, the nurse identifies a nursing diagnosis of acute pain related to decreased coronary blood flow. A priority nursing intervention for this patient would be to

a.

promote rest to decrease myocardial oxygen demand.

b.

teach the patient about the need for anticoagulant therapy.

c.

teach the patient to use sublingual nitroglycerin for chest pain.

d.

raise the head of the bed 60 degrees to decrease venous return.

ANS: A

Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation.

DIF: Cognitive Level: Apply (application) REF: 823 | 826

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

17. During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient on the

a.

use of daily aspirin for anticoagulation.

b.

correct method for taking the radial pulse.

c.

need for frequent laboratory blood testing.

d.

need to avoid any physical activity for 1 month.

ANS: C

Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve. This will require frequent international normalized ratio (INR) testing. Daily aspirin use will not be effective in reducing the risk for clots on the valve. Monitoring of the radial pulse is not necessary after valve replacement. Patients should resume activities of daily living as tolerated.

DIF: Cognitive Level: Apply (application) REF: 826

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

18. A patient recovering from heart surgery develops pericarditis and complains of level 6 (0 to 10 scale) chest pain with deep breathing. Which ordered PRN medication will be the most appropriate for the nurse to give?

a.

Fentanyl 1 mg IV

b.

IV morphine sulfate 4 mg

c.

Oral ibuprofen (Motrin) 600 mg

d.

Oral acetaminophen (Tylenol) 650 mg

ANS: C

The pain associated with pericarditis is caused by inflammation, so nonsteroidal antiinflammatory drugs (NSAIDs) (e.g., ibuprofen) are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis.

DIF: Cognitive Level: Apply (application) REF: 816

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of

a.

flank pain.

b.

splenomegaly.

c.

shortness of breath.

d.

mental status changes.

ANS: C

Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, changes in mental status, and splenomegaly would be associated with embolization from the left-sided valves.

DIF: Cognitive Level: Apply (application) REF: 812

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

20. A patient admitted with acute dyspnea is newly diagnosed with dilated cardiomyopathy. Which information will the nurse plan to teach the patient about managing this disorder?

a.

A heart transplant should be scheduled as soon as possible.

b.

Elevating the legs above the heart will help relieve dyspnea.

c.

Careful compliance with diet and medications will prevent heart failure.

d.

Notify the doctor about any symptoms of heart failure such as shortness of breath.

ANS: D

The patient should be instructed to notify the health care provider about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure. Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy). The patient with terminal or end-stage cardiomyopathy may consider heart transplantation.

DIF: Cognitive Level: Apply (application) REF: 828

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

21. The nurse is obtaining a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC). Which information obtained by the nurse is most important?

a.

The patient has a history of a recent upper respiratory infection.

b.

The patient has a family history of coronary artery disease (CAD).

c.

The patient reports using cocaine a couple of times as a teenager.

d.

The patients 29-year-old brother died from a sudden cardiac arrest.

ANS: D

About half of all cases of HC have a genetic basis, and it is the most common cause of sudden cardiac death in otherwise healthy young people. The information about the patients brother will be helpful in planning care (such as an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family members. The patient should be counseled against the use of stimulant drugs, but the limited past history indicates that the patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy, but not for HC.

DIF: Cognitive Level: Apply (application) REF: 828

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

22. The nurse will plan discharge teaching about the need for prophylactic antibiotics when having dental procedures for which patient?

a.

Patient admitted with a large acute myocardial infarction.

b.

Patient being discharged after an exacerbation of heart failure.

c.

Patient who had a mitral valve replacement with a mechanical valve.

d.

Patient being treated for rheumatic fever after a streptococcal infection.

ANS: C

Current American Heart Association guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.

DIF: Cognitive Level: Apply (application) REF: 813

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

23. Which admission order written by the health care provider for a patient admitted with infective endocarditis (IE) and a fever would be a priority for the nurse to implement?

a.

Administer ceftriaxone (Rocephin) 1 g IV.

b.

Order blood cultures drawn from two sites.

c.

Give acetaminophen (Tylenol) PRN for fever.

d.

Arrange for a transesophageal echocardiogram.

ANS: B

Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity results. The echocardiogram and acetaminophen administration also should be implemented rapidly, but the blood cultures (and then administration of the antibiotic) have the highest priority.

DIF: Cognitive Level: Apply (application) REF: 812-813

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

24. Which assessment finding in a patient who is admitted with infective endocarditis (IE) is most important to communicate to the health care provider?

a.

Generalized muscle aching

b.

Sudden onset right flank pain

c.

Janeways lesions on the palms

d.

Temperature 100.7 F (38.1 C)

ANS: B

Sudden onset of flank pain indicates possible embolization to the kidney and may require diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion. The other findings are typically found in IE, but do not require any new interventions.

DIF: Cognitive Level: Apply (application) REF: 812

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

25. Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider?

a.

Pulsus paradoxus 8 mm Hg

b.

Blood pressure (BP) of 168/94

c.

Jugular venous distention (JVD) to jaw level

d.

Level 6 (0 to 10 scale) chest pain with a deep breath

ANS: C

The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis.

DIF: Cognitive Level: Apply (application) REF: 815

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

26. The nurse is caring for a 78-year-old patient with aortic stenosis. Which assessment data obtained by the nurse would be most important to report to the health care provider?

a.

The patient complains of chest pressure when ambulating.

b.

A loud systolic murmur is heard along the right sternal border.

c.

A thrill is palpated at the second intercostal space, right sternal border.

d.

The point of maximum impulse (PMI) is at the left midclavicular line.

ANS: A

Chest pressure (or pain) occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.

DIF: Cognitive Level: Apply (application) REF: 823

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

27. Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain that increases with a deep breath. Which action will the nurse take first?

a.

Auscultate the heart sounds.

b.

Check the patients temperature.

c.

Notify the patients health care provider.

d.

Give the PRN acetaminophen (Tylenol).

ANS: A

The patients clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature and notifying the health care provider are also appropriate actions but would not be done before listening for a rub. It is not stated for what symptom (e.g., headache) or finding (e.g., increased temperature) the PRN acetaminophen (Tylenol) is ordered.

DIF: Cognitive Level: Apply (application) REF: 815

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

28. The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately?

a.

The patient has bilateral crackles.

b.

The patient has bilateral, 4+ peripheral edema.

c.

The patient has a loud systolic murmur across the precordium.

d.

The patient has a palpable thrill felt over the left anterior chest.

ANS: A

Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.

DIF: Cognitive Level: Apply (application) REF: 821-822

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

29. Which action by the nurse will determine if the therapies ordered for a patient with chronic constrictive pericarditis are effective?

a.

Assess for the presence of a paradoxical pulse.

b.

Monitor for changes in the patients sedimentation rate.

c.

Assess for the presence of jugular venous distention (JVD).

d.

Check the electrocardiogram (ECG) for ST segment changes.

ANS: C

Because the most common finding on physical examination for a patient with chronic constrictive pericarditis is jugular venous distention, a decrease in JVD indicates improvement. Paradoxical pulse, ST-segment ECG changes, and changes in sedimentation rates occur with acute pericarditis but are not expected in chronic constrictive pericarditis.

DIF: Cognitive Level: Apply (application) REF: 817

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

30. Which statement by a patient with restrictive cardiomyopathy indicates that the nurses discharge teaching about self-management has been most effective?

a.

I will avoid taking aspirin or other antiinflammatory drugs.

b.

I will need to limit my intake of salt and fluids even in hot weather.

c.

I will take antibiotics when my teeth are cleaned at the dental office.

d.

I should begin an exercise program that includes things like biking or swimming.

ANS: C

Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use prophylactic antibiotics for any procedure that may cause bacteremia. The other statements indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt (unless ordered), aspirin, or NSAIDs.

DIF: Cognitive Level: Apply (application) REF: 830 | 813

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

31. The nurse is assessing a patient with myocarditis before administering the scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider?

a.

Leukocytosis

b.

Irregular pulse

c.

Generalized myalgia

d.

Complaint of fatigue

ANS: B

Myocarditis predisposes the heart to digoxin-associated dysrhythmias and toxicity. The other findings are common symptoms of myocarditis and there is no urgent need to report these.

DIF: Cognitive Level: Apply (application) REF: 818

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

32. After receiving report on the following patients, which patient should the nurse assess first?

a.

Patient with rheumatic fever who has sharp chest pain with a deep breath

b.

Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg

c.

Patient with infective endocarditis who has a murmur and splinter hemorrhages

d.

Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases

ANS: B

Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea or chest pain. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention.

DIF: Cognitive Level: Analyze (analysis) REF: 823

OBJ: Special Questions: Multiple Patients; Prioritization

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

33. After receiving the following information about four patients during change-of-shift report, which patient should the nurse assess first?

a.

Patient with acute pericarditis who has a pericardial friction rub

b.

Patient who has just returned to the unit after balloon valvuloplasty

c.

Patient who has hypertrophic cardiomyopathy and a heart rate of 116

d.

Patient with a mitral valve replacement who has an anticoagulant scheduled

ANS: B

The patient who has just arrived after balloon valvuloplasty will need assessment for complications such as bleeding and hypotension. The information about the other patients is consistent with their diagnoses and does not indicate any complications or need for urgent assessment or intervention.

DIF: Cognitive Level: Analyze (analysis) REF: 824

OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

34. Which action could the nurse delegate to unlicensed assistive personnel (UAP) trained as electrocardiogram (ECG) technicians working on the cardiac unit?

a.

Select the best lead for monitoring a patient with an admission diagnosis of Dressler syndrome.

b.

Obtain a list of herbal medications used at home while admitting a new patient with pericarditis.

c.

Teach about the need to monitor the weight daily for a patient who has hypertrophic cardiomyopathy.

d.

Check the heart monitor for changes in rhythm while a patient who had a valve replacement ambulates.

ANS: D

Under the supervision of registered nurses (RNs), UAP check the patients cardiac monitor and obtain information about changes in heart rate and rhythm with exercise. Teaching and obtaining information about home medications (prescribed or complementary) and selecting the best leads for monitoring patients require more critical thinking and should be done by the RN.

DIF: Cognitive Level: Apply (application) REF: 15

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

35. The nurse is caring for a patient with mitral regurgitation. Referring to the figure below, where should the nurse listen to best hear any murmur that the patient has?

a.

1

b.

2

c.

3

d.

4

ANS: D

Sounds from the mitral valve are best heard at the apex of the heart, fifth intercostal space, midclavicular line.

DIF: Cognitive Level: Understand (comprehension) REF: 821

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Leave a Reply