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Med Surg Midterm NCLEX Style - Cardio
Vascular
A nurse is preparing to administer pain medication to a patient who is experiencing pain in his chest from myocardial ischemia. Which factor would the nurse most likely consider when giving pain medication to this patient? A. The patient should learn to notify the nurse if the pain medicine is working B. The patient is at risk of aspirating the medication C. The patient will need to sleep after taking this medication D. The patient should receive oxygen when the pain occurs - D. Rationale: "The patient should receive oxygen when the pain occurs" is correct. Management for angina pectoris due to myocardial ischemia includes a pain assessment, pain medications, administering oxygen, assessing vital signs and monitoring cardiac status. Morphine and nitroglycerin are common pain medications given for angina. Angina can occur when the heart is not getting enough oxygen, so the nurse recognizes that the patient should receive oxygen to correct this. A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? A. Assess the clients support system. B. Assist in finding one change the client can control. C. Determine what stressors the client faces in daily life. D. Inquire about delegating some of the clients obligations. - B. Rationale: All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the clients feelings of control. A 56-year-old client is being seen at the primary care clinic for follow-up after having chest pain. The client tells the nurse, "I think I had a heart attack yesterday but it could have just been chest pain. It still hurts some, though." The provider orders a troponin level and an ECG. Which response from the nurse is most appropriate? A. The ECG level may show damage to your heart, but the troponin level will no longer be accurate B. If you had a heart attack, the ECG will be back to normal now. We just need this as a baseline C. Both the ECG and troponin levels may be abnormal, even if the heart attack was yesterday D. If you had come in when you were having chest pains, we would have more accurate outcomes. These results may be skewed now - C.
Rationale: "Both the ECG and troponin levels may be abnormal, even if the heart attack was yesterday" is correct. A client may experience a heart attack but may not necessarily know if it was an actual myocardial infarction or simply angina. The outcome may not be obvious right away, but laboratory levels can be drawn that will demonstrate changes in cardiac enzymes showing if the client actually suffered damage to the heart muscle. The troponin levels may remain abnormal for up to ten days after a heart attack. Additionally, an ECG may also demonstrate changes as part of the fully evolved post- myocardial stage, which occurs within hours to days after a heart attack. A 74-year-old client has suffered a myocardial infarction; the critical care team places the client into a state of hypothermia as part of treatment. Which best describes why hypothermia is used after cardiac arrest? A. Hypothermia protects the brain from damage caused by ischemia by slowing the brain's metabolism B. Hypothermia prevents other complications from developing, such as hypoglycemia and seizures C. Hypothermia prevents the body from secreting hormones that could further damage ischemic tissue D. Hypothermia stops blood flow that would otherwise cause an immune response and inflammation - A. Rationale: "Hypothermia protects the brain from damage caused by ischemia by slowing the brain's metabolism" is correct. Therapeutic hypothermia, also known as targeted temperature management (TTM) is a form of treatment that may be used among some clients who have suffered a cardiac arrest. A client may be placed in a state of hypothermia after a myocardial infarction when his heart and brain have suffered damage from lack of oxygen. Research has shown that therapeutic hypothermia protects the brain from ischemic damage by slowing the brain's metabolism, resulting in improved neurological outcomes. The nurse is admitting a client who states, "When I was pregnant I would get heartburn so bad, I was eating antacids like crazy. I now feel the same way, except I am not pregnant. The antacids aren't helping me and now I have this pain between my shoulder blades." Which part of this statement is most concerning and must be investigated further? A. "I have this pain between my shoulder blades" B. "When I was pregnant I would get heartburn so bad" C. "The antacids aren't helping me" D. "I was eating antacids like crazy" - A. Rationale: This female client is showing signs of a myocardial infarction. Women often present with atypical symptoms and will often describe a feeling of acid reflux that is actually a heart attack. This client needs an EKG (ECG) immediately to rule out a STEMI. A 44-year-old client is recovering in the hospital following a myocardial infarction. The client asks the nurse about participation in cardiac rehabilitation. Which of the following is an accurate explanation of cardiac rehabilitation? A. Cardiac rehabilitation can help you to improve activity levels and exercise tolerance after a heart attack B. Cardiac rehabilitation is designed only for people who were born with congenital heart disease and have experienced a heart attack C. Cardiac rehabilitation is designed for people over the age of 60 for additional physical therapy after a heart attack D. Cardiac rehabilitation is designed to teach a person what to do if they have a heart attack again -
D. Hydromorphone - A. Rationale: "Heparin" is correct. Heparin is an anticoagulant that is commonly used to prevent blood clots, but is also used as anticoagulant therapy for myocardial infarctions. A client who has recovered from a heart attack has been moved to a different unit in the hospital and placed on telemetry. As the nurse is connecting the electrodes to the client, he says, "Why do I have to wear this?" What information should the nurse give this client about telemetry? Select all that apply. A. The telemetry will monitor the client's heart rhythm during his hospital stay B. The electrodes on the chest are leads connected to wires that transmit signals to the monitor C. The telemetry allows the client's heart rate to be monitored from a desk outside of the room D. The telemetry is always monitored by a physician E. The client will not be able to ambulate while being monitored by telemetry - A. , B. , C. Rationale: "The telemetry will monitor the client's heart rhythm during his hospital stay", "The telemetry allows the client's heart rate to be monitored from a desk outside of the room" and "The electrodes on the chest are leads connected to wires that transmit signals to the monitor" are correct. Telemetry is a system of cardiac rhythm monitoring that can be done from a remote area of the building. The client is connected to a telemetry box that sends signals to a central location, which is constantly monitored by a telemetry technician. An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? A. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers B. A 49-year-old male who reports moderate pain that is worse on inspiration C. A 53-year-old female who reports substernal pain that radiates to her abdomen D. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest - D. Rationale: All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the clients chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction. A 77-year-old client is seen in the ED for chest pain. The provider orders lab work to determine if damage has been done to the heart muscle. Which lab test is a cardiac enzyme that would be ordered to check for heart damage? A. CK-MB B. Diastase C. Bromelain D. Phytase -
A.
Rationale: "CK-MB" is correct. When a myocardial infarction occurs, the damaged myocardium releases certain enzymes into the bloodstream. By checking for an elevation in the enzymes, the provider can determine if damage has been done to the heart muscle. The types of cardiac enzymes checked include troponins and creatine-kinase myocardial bands (CK-MB). The nurse is caring for a client with heart failure. The nurse knows that the client is experiencing right- sided heart failure based on which assessment? A. Shortness of breath upon exertion B. Coarse crackles in the lungs C. Pitting edema in the bilateral legs D. Fixed pupils - C. Rationale: "Pitting edema in the bilateral legs" is correct. In right-sided heart failure, fluid backs up to the body, not the lungs. This causes edema in the lower extremities. A student nurse is taking an exam on the cardiovascular system and knows that which of the following symptoms would be the most concerning? A. Swollen right leg that is red and hot to touch B. Swollen bilateral legs with +4 pitting edema C. Right leg with a venous stasis ulcer D. Swollen left leg with weeping wounds - A. Rationale: Redness and warmth are signs and symptoms of a DVT. The concern with a DVT is that it will break free and cause a pulmonary embolism, stroke or myocardial infarction. A nurse is caring for a client with heart failure. During the shift assessment the nurse notes that the client has pitting edema, shortness of breath, and which heart sound? A. Gallop B. Rubbing C. Clicking D. Swooshing - A. Rationale: If a gallop sound (S3) is heard, this indicates blood prematurely rushing into the ventricle. This is often related to volume overload as seen in heart failure, but could also be caused by pulmonary hypertension or coronary artery disease. A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? A. Compare the results with previous pulmonary artery pressure readings. B. Increase the intravenous fluid rate because these readings are low. C. Immediately notify the health care provider of the elevated pressures. D. Document the finding in the clients chart as the only action. - A.
preload, lessen anxiety and reduce the work of breathing. As always, the nurse documents everything - the event, actions taken, and the response of the client. A patient with heart failure has been ordered to reduce her sodium intake in order to better control her condition. Which best explains why reduction in sodium intake will affect symptoms of heart failure? A. Increased dietary sodium leads to greater risk of atherosclerosis B. Increased sodium intake damages the heart valves and affects circulation C. Too much sodium has been shown to cause cardiac dysrhythmias D. Too much sodium intake is associated with fluid retention - D. Rationale: Fluid retention is a risk for patients with fluid retention which causes volume overload associated with heart failure. Most patients with heart failure are counseled to avoid excess sodium and they often need to take medications to eliminate excess fluid from the body. The nurse knows that the client is experiencing left-sided heart failure based on which of the following assessments? Select all that apply. A. Cheyne-stokes respirations B. Dyspnea C. Liver enlargement D. Pulmonary edema E. Pitting leg edema - B. , D. Rationale: In heart failure, LEFT backs up to the LUNGS, while RIGHT backs up to the REST of the body. Therefore pulmonary edema and dyspnea would be symptoms of left-sided heart failure. The left side of the heart backs up to the lungs, so pulmonary edema is seen in left-sided heart failure. The nurse is caring for a client who is suffering from heart failure. The client has been experiencing weight gain and peripheral edema. Which of the following interventions should the nurse employ? A. Monitor the client's intake and output every 24 hours B. Auscultate breath sounds at least every 2 hours C. Keep the client's legs in the dependent position D. Place the client on a low-magnesium diet - B. Rationale: "Auscultate breath sounds at least every 2 hours" is correct. Fluid volume excess develops when the client has excess circulating volume in the bloodstream or the body is retaining enough fluid to cause fluid to move to the tissues outside of circulation. It may be manifested by such signs or symptoms as swelling, wet breath sounds, and weight gain. Nursing interventions include reducing edema, checking breath sounds regularly for changes, and monitoring intake and output at least every 4 hours. Placing the legs in the dependent position would allow for further fluid accumulation in the extremities. The nurse is caring for a client who was admitted with shortness of breath and has a new diagnosis of heart failure. Which of the following labs indicate that the client is suffering from severe heart failure? A. BNP 850 pg/mL B. LDL 19.2 mmHg C. LDL 192 mg/dL
D. BNP 85 pg/mL - A. Rationale: BNP helps quantify the severity of heart failure. A BNP from 600-900 pg/mL indicates severe heart failure. A patient with heart failure is being treated for exacerbation of symptoms. The physician has ordered a dose of milrinone to be given IV. Which best describes a property of this type of medication? A. Increasing preload B. Decreasing afterload C. Decreasing contractility D. Regulating heart arrhythmia - B. Rationale: Milrinone increases the size of blood vessels, which reduces the pressure the heart must work against during contractions. Therefore, afterload is decreased and blood flow is improved. Milrinone is used for short-term management of heart failure. A nurse is preparing to administer furosemide to a patient who is in the hospital with heart failure. Which of the following should the nurse consider when administering this medication? A. Monitor the patient's temperature every 4 hours B. Do not administer the medication with meals C. Give the dose early in the day D. Decrease fluid intake to avoid excess urine secretion - C. Rationale: "Give the dose early in the day" is correct. Furosemide is a diuretic medication that reduces excess fluid through urination. When giving this medication, the nurse should give it early in the day, as it will cause the patient to need to use the bathroom frequently. The nurse should avoid giving it in the evening, because it will disrupt sleep if the patient has to get up multiple times during the night to urinate. A client has been admitted to the cardiac unit with exacerbation of heart failure symptoms. The nurse has given him a nursing diagnosis of decreased cardiac output related to heart failure, as evidenced by a poor ejection fraction, weakness, edema, and decreased urinary output. Which of the following nursing interventions is the most appropriate in this situation? A. Administer stool softeners as ordered B. Maintain the client in the Trendelenburg position while in bed C. Administer IV fluid boluses to increase urinary output D. Increase activity by encouraging ambulation - A. Rationale: "Administer stool softeners as ordered" is correct. When a client has a nursing diagnosis of decreased cardiac output, the nurse should avoid any activities that would put undue stress on the client's heart. In this situation, the nurse can administer stool softeners so that the client does not have to strain to have a bowel movement, which would place less stress on the heart.
Rationale: "Increased cardiac output and decreased blood pressure" is correct. Enalapril (Vasotec) is a drug typically used to treat high blood pressure and heart failure in adults. Enalapril works to increase cardiac output and decrease blood pressure among patients with hypertension. It is considered an ACE inhibitor, or angiotensin converting enzyme inhibitor. The nurse is caring for a client taking lisinopril. The nurse knows that this medication works by doing which of the following? Select all that apply. A. Decreasing afterload B. Increasing contractility C. Increasing preload D. Decreasing preload E. Increasing afterload - A. , D. Rationale: "Decreasing preload" and "Decreasing afterload" are correct. Lisinopril is an ACE inhibitor, commonly used in heart failure clients to decrease the work of the heart by decreasing preload and afterload. ACE inhibitors accomplish this by blocking the renin angiotensin aldosterone system, which allows blood vessels to dilate. A patient with acute decompensated heart failure has been prescribed intravenous diuretic medications to control fluid and congestion. Which nursing intervention would the nurse need to perform in order to best monitor fluid and electrolyte balance in this patient? A. Insert a Foley catheter B. Check the patient's weight daily C. Monitor for signs of pancreatic dysfunction D. Administer pain medications as ordered - B. Rationale: Decompensated heart failure can cause a patient to experience fluid overload, leading to difficulties with breathing and increased amounts of fluid in peripheral tissues (edema). In this case the nurse should weigh the patient daily and record it. If the patient is retaining fluid, he will gain weight. The nurse is caring for a client with a cardiac diet ordered. This client should choose foods that are low in which of the following? Select all that apply. A. Fiber B. Carbohydrates C. Protein D. Fat E. Sodium - D. , E. Rationale: "Fat" is correct. Cardiac diets are low in fat because fats increase the risk for heart disease. "Sodium" is correct. A cardiac diet is low in sodium because sodium increases water retention and blood pressure. Diuretics are good medications for the management of hypertension because of which of the following mechanisms?
A. Promote sodium depletion, decreasing intravascular volume B. Block alpha receptors in the blood vessels, lessening vascular tone C. Dilate blood vessels, decreasing vascular pressure D. Inhibit angiotensin converting enzyme, preventing vasoconstriction - A. Rationale: Diuretics reduce blood pressure by promoting sodium and water depletion, which decreases intravascular volume. A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? A. I have been drinking more water than usual. B. I am awakened by the need to urinate at night. C. I must stop halfway up the stairs to catch my breath. D. I have experienced blurred vision on several occasions. - C. Rationale: Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or catching their breath. This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure. The floor nurse is receiving report from an ED nurse on a client being admitted for cellulitis of the right leg. The client also is experiencing hypertension. Which question is a priority for the floor nurse to ask the ED nurse? A. What was the last blood pressure? B. How often are we giving the antibiotic? C. Did the client get any medications for the BP? D. Is the client experiencing hypertensive symptoms? - D. Rationale: Asking if the client is experiencing symtpoms of hypertension is important to make a clinical prioritization. The ED nurse should have already addressed the hypertension, but out of the answers listed, this is the biggest priority for the floor nurse to clarify. If the client is symptomatic, the nurse would contact the provider and the client would have an ECG. A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? A. I sleep with four pillows at night. B. My shoes fit really tight lately. C. I wake up coughing every night. D. I have trouble catching my breath. - B. Rationale: Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left-sided heart failure.
medication but is currently hypertensive. Which medication should the nurse confirm the client took today? A. Atrovastatin B. Atenolol C. Atropine D. Acyclovir - B. Rationale: "Atenolol" is correct. Atenolol is an anti-hypertensive beta blocker that is used for hypertension, as well as angina and prevention of an MI. The nurse is caring for a client with a hypertensive crisis. The nurse is monitoring for signs and symptoms that would indicate either an urgent or an emergent situation. Which of the following signs indicate an emergent situation? Select all that apply. A. Confusion B. Slurred speech C. Shortness of breath D. Crackles in the lungs E. Anxiety - A. , B., D. Rationale: Confusion is a stroke-like symptom and indicates a medical emergency. Other stroke symptoms include facial drooping, one sided weakness, and slurred speech. Slurred speech is a stroke- like symptom and indicates a medical emergency. Other stroke symptoms include facial drooping, one sided weakness, and confusion. Crackles in the lungs indicates increased pulmonary hypertension and is a sign that the hypertensive crisis has progressed to an emergent situation. While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? A. Assess for symptoms of left-sided heart failure. B. Document this as a normal finding. C. Call the health care provider immediately. D. Transfer the client to the intensive care unit. - A. Rationale: The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted. The nurse is caring for a client with a hypertensive crisis. This situation becomes a medical emergency when the client shows which sign or symptom? Select all that apply. A. Facial drooping B. Headache C. Loss of consciousness D. Epistaxis E. Chest pain - A. , C., E. Rationale: A hypertensive crisis can be urgent, or it can be an emergency. Both scenarios include a blood pressure with a MAP over 120 mm Hg and/or systolic pressures over 180 mm Hg. A
hypertensive crisis becomes emergent when stroke-like symptoms, myocardial infarction (MI) symptoms, and loss of consciousness occur. This client will need IV blood pressure medication to immediately lower the blood pressure.If a client is in a hypertensive crisis, loss of consciousness or new-onset lung crackles indicate a medical emergency.This is sign of an MI, and indicates a medical emergency. The nurse is reviewing a client's medication list and notes that the client has a history of hypertension based on which of the following medications? A. Epoetin B. Escitalopram C. Enalapril D. Enoxaparin - C. Rationale: "Enalapril" is correct. Enalapril is an ACE inhibitor that helps to manage hypertension and CHF, and is the only medication out of the choices that has a blood pressure lowering effect. The provider orders an antihypertensive medication for a client whose blood pressure is 205/110 mm Hg. The nurse reviews the medication administration record and sees an order for which of the following blood pressure medications? A. Nalbuphine B. Nystatin C. Neomycin D. Nitroprusside - D. Rationale: "Nitroprusside" is correct. This is a antihypertensive medication used during a hypertensive crisis. A client with peripheral artery disease is suffering from ineffective tissue perfusion. Which of the following would be appropriate outcomes for this nursing diagnosis? Select all that apply. A. The client will be free from respiratory distress B. The client will verbalize the need for adequate fluid and nutrition intake C. The client will have palpable peripheral pulses D. The client will have adequate urinary output E. The client's skin will be warm and dry - B. , C. , D. , E, Rationale: "The client will have palpable peripheral pulses", "The client's skin will be warm and dry", "The client will have adequate urinary output", and "The client will verbalize the need for adequate fluid and nutrition intake" are correct. Ineffective tissue perfusion as a result of peripheral artery disease can lead to decreased oxygenation of distal tissues and potential organ dysfunction. The nurse can set goals for the client while he is being treated for his condition. Potential goals include that the client will have adequate circulation, normal fluid volume, and adequate urine output. Urine output is a direct measurement of cardiac output, so the nurse knows that when the client is producing adequate urine, the cardiovascular system is functioning and the client's fluid status is adequate as well.
The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? A. Cholesterol: 125 mg/dL B. High-density lipoprotein cholesterol (HDL-C): 47 mg/dL C. Low-density lipoprotein cholesterol (LDL-C): 120 mg/dL D. Triglycerides: 218 mg/dL - D. Rationale: Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males. A 28-year-old client with no history of heart disease asks the nurse about whether to have cholesterol checks and how often this should be monitored. Which answer from the nurse is correct? A. You do not need to have your cholesterol checked until you are 40 since you are low risk B. Once you turn 30, you should have your cholesterol checked with each physical exam C. You will need to have it checked now. Cholesterol should be checked every 6 months D. We will check it now. Cholesterol should be checked every 4 to 6 years since you are low risk - D. Rationale: Because high cholesterol levels contribute to atherosclerosis, a client should be checked periodically to ensure that cholesterol levels remain within normal limits. A client without a history of heart disease or cholesterol problems should have their cholesterol checked starting at age 20 and then routinely every 4 to 6 years. A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? A. Could you walk further than that a few months ago? B. Do you walk mostly uphill, downhill, or on flat surfaces? C. Have you ever considered swimming instead of walking? D. How much pain medication do you take each day? - A. Rationale: As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the clients disease is worsening. The other questions are useful, but not as important. A client in the healthcare clinic has an order for total cholesterol levels because of his history of heart disease. The nurse provides information to this client about the upcoming test. Which of the following is true information regarding the results of this type of test? Select all that apply. A. The total cholesterol is a measurement of HDL, LDL, and other components B. The ideal range for total cholesterol is less than 200 mg/dL C. The client must fast for at least 16 hours before the test D. A higher level of total cholesterol means a lower risk of heart disease E. A lower level of total cholesterol could indicate an increased risk of atherosclerosis - A, B. Rationale: "The total cholesterol is a measurement of HDL, LDL, and other components", and "The ideal range for total cholesterol is less than 200 mg/dL" are correct. A total cholesterol test, also called
a lipid profile, is a combination test that measures levels for HDL, LDL, and triglycerides. The ideal range for the test is less than 200 mg/dL. The client should fast for 9-12 hours before the test for most accurate results, drinking only water during that time. A nurse is checking laboratory results for a patient with TPN and lipids and notes the following: Sodium: 138 mEq/L Potassium: 4.1 mEq/L Calcium: 10.1 mg/dL Albumin: 5.4 g/dL Triglycerides: 426 mg/dL Alkaline Phosphatase: 100 IU/L Based on these laboratory results, which of the following actions is most appropriate? A. Flush the catheter with saline B. Add normal saline solution to the TPN fluid C. Obtain an order to discontinue the lipid infusion D. Administer a thrombolytic agent as ordered - C. Rationale: "Obtain an order to discontinue the lipid infusion" is correct. The patient in the scenario has high triglyceride levels, which is a potential complication of TPN administration with lipids. The first action of the nurse would be to discontinue the lipid infusion with the healthcare provider's permission and then monitor the triglyceride levels to see if they return to normal. A nurse is monitoring her patient who is in the medical-surgical unit with a recent bowel resection. The patient has an infusion of TPN with lipids running into a central line. Which of the following metabolic complications would the nurse most likely see with a patient receiving TPN? A. Hypoalbuminemia B. Hyponatremia C. Hypermagnesemia D. Hypertriglyceridemia - D. Rationale: - "Hypertriglyceridemia" is correct. A patient who receives TPN is at higher risk of certain metabolic complications, including hypo- or hyperglycemia, refeeding syndrome and hypertriglyceridemia. TPN contains a mixture of several vitamins and electrolytes, as well as dextrose and lipids. When a lipid emulsion is added, the patient may be at higher risk of developing elevated triglycerides. A healthy adult female who is not at increased risk of heart disease should have her blood cholesterol checked how often? A. At least every 6 years starting at age 20 B. At least every 10 years starting at age 18 C. At least every year starting at age 20 D. At least every year starting at age 35 - A. Rationale: Both men and women should start having their cholesterol checked at age 20 and every 4- 6 years after if they are not at high risk of heart disease. Some clients, particularly those who are at increased risk of atherosclerosis or who have been shown to have high cholesterol, may need to have their levels checked more often.
B. Left lateral chest wall pain C. Disorientation and confusion D. Numbness and tingling of the arm - C. Rationale: In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion. A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? A. Elevate the leg and apply a sandbag to the entrance site. B. Increase the flow rate of intravenous fluids. C. Assess the color and temperature of the left leg. D. Document the finding as left pedal pulse of +1/4. - C. Rationale: Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the clients problem.
