<P> client is prescribed sublingual nitroglycerine for the treatment of angina

<Q>A
<TYPE>single</TYPE>
pectoris. The nurse concludes that what response from the client indicates under
standing healthcare
<MC1>"My of this medication?</Q>
provider gave me a year's supply of nitroglycerine tablets."
<MC2>"I will carry my nitroglycerine tablets in the inside pocket of my jacket,
</MC1>
so they usually
<MC3>"I are alwaystakeclose."</MC2>
three of my nitroglycerine tablets at the same time. I find
<MC4>"I
that they
havework
a small
bettermetal
thatlabeled
way."</MC3>
case for a few nitroglycerine tablets that I
carry with me Nitroglycerine
<F>Rationale:
<CORRECT>4</CORRECT>
when I go out."</MC4>
tables are light sensitive and should be stored in
a dry, dark container (option 4). Nitroglycerine loses potency over time and sho
uld be replaced every 6 months or sooner as needed (option 1). Exposure to moist
ure, light, or to heat, as in the pocket of a jacket (option 2) may decrease the
effectiveness of the tablet. One nitroglycerine tablet should be taken at a tim
e five minutes apart (option 3); taking more that one tablet at a time can actua
lly cause
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
severe
Level:
The
Process:
Physiological
Pharmacology
core hypotension.
Application
issue
Nursing
ofIntegrity:
Process:
the question
Evaluation
Pharmacological
is knowledge of andthe
Parenteral
proper use
Therapies
and stor
age of nitroglycerin tablets. Recall the proper dosage sequence, the 6-month tim
e frame as the limit for storage, and recall that light, heat, and moisture degr
ade the tablets
Reference: LeMone,
to P.,
aid &inBurke,
makingK.the(2008).
correct<i>Medical-surgical
selection. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 973.</F>
<Q>The
<TYPE>multi</TYPE>
<P>
</P> nurse is caring for a client with a diagnosis of first-degree heart block
. The nurse anticipates that the client's cardiac rhythm strip will reveal which
<MC1>Number
<MC2>PR
<MC3>QT
<MC4>P
<MC5>PR
<F>Rationale:
<CORRECT>[2,5]</CORRECT>
of thewave
following?
segment
interval
ofInQRS
rate isfirst-degree
isprolonged</MC3>
Select
complexes
consistent</MC2>
usually
prolonged</MC5>
allslower
are
thathalf
heart apply.</Q>
than
block,
thethenumber
the
QRSPRrate</MC4>
ofinterval
P waves</MC1>
is prolonged (> 0.20
second) but consistent in length from complex to complex (options 2 and 5). The
number of P waves and QRS complexes are equal in number (options 1 and 4). The Q
T segment could become prolonged because of the effects of some anti-dysrhythmic
Cognitive
Client
Integrated
Content
Strategy:
drugs Need:
(option
Area:
Level:
Review
Process:
Physiological
Adult
3).the
Analysis
Nursing
Health:
characteristics
Integrity:
Process: of
Cardiovascular
Assessment
Reduction
the various
of Risk
formsPotential
of heart block. The cr
itical words <i>first-degree</i> are essential to answering the question. Keep i
n mind that this form of heart block is mildest to help make the correct selecti
Reference: Smith, S. F., Duell, D. J., & Martin, B. C. (2008). <i>Clinical nursi
ons.
ng skills: Basic to advanced skills</i> (7th ed.). Upper Saddle River, NJ: Pears
on Education,
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse ispp.caring
1003-1004.</F>
for a client who has just returned from the cardiac cathe
terization lab following a percutaneous transluminal coronary angioplasty (PTCA)
. The client is receiving a continuous infusion of heparin. The urine is now tea
<MC1>Notify
<MC2>Monitor
<MC3>Assess
colored. Whatthe
theaction
healthcare
insertion
urineshould
forsite
provider
anythefor
additional
nurse
bleeding
andtake
askchange
next?</Q>
for
and aninorder
measure
color.</MC2>
pulse
for anandaPTT.</MC1>
blood pressure
<MC4>Ask the client
.</MC3>
<F>Rationale:
<CORRECT>3</CORRECT>
Heparinifisthere
an anticoagulant
is any chest thatpain.</MC4>
is given following a PTCA to prev
ent clot formation at the site of the PTCA. If the therapeutic level of heparin
is exceeded, the client may bleed. Tea-colored urine is a sign of blood in the u
rine and additional assessment data is needed regarding other possible sources o
f bleeding or hypovolemia due to hemorrhage (option 3). Once this additional imp
ortant data is gathered quickly, the healthcare provider would be notified (opti
on 1). Further observation of the color of the urine could potentially worsen th
e bleeding as the coagulation profile would be further prolonged (option 2). Whi
le the nurse will ask the client if chest pain is present after an angioplasty b
ecause of the risk of coronary spasm, there is no relationship between tea color
ed urineNeed:
Cognitive
Client
Integrated
Content
Strategy:Area:
and
Level:
The
Process:
chest
Physiological
Adult
core Analysis
pain
issue
Nursing
Health:
(option
ofIntegrity:
Process:
Cardiovascular
this 4).
question
Implementation
Reduction
is knowledge
of RiskofPotential
bleeding as a side eff
ect of heparin therapy and appropriate additional assessments that are needed. T
he critical word in the question is <i>next</i>. Consider that the nurse does no
t report a single data point to the healthcare provider without gathering additi
onal data, toLeMone,
References: enableP., you&toBurke,
chooseK.correctly.
(2008). <i>Medical-surgical nursing: Critica
l thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educati
on, pp.nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 1189-1190.</F>
is caring for a client being discharged after valve replacement sur
gery using a St. Jude mechanical valve. The nurse is reviewing the instructions
for the client's follow-up care and determines that the client understands the i
nstructions
<MC1>"I willwhen
takethewarfarin
client(Coumadin)
states:</Q>for 2 months and get my blood drawn every
week until
<MC2>"I willI remind
stop taking
the doctor
the drug."</MC1>
to give me a prescription for anticoagulant medic
ation every
<MC3>"I willtime
needItogotake
to the
anticoagulant
dentist."</MC2>
medication for the rest of my life."</MC
<MC4>"I won't take any anticoagulant medication or blood thinners because they m
3>
ay cause a problem
<F>Rationale:
<CORRECT>3</CORRECT>
A mechanical
with my valve
new valve."</MC4>
requires life-long anticoagulation therapy to d
ecrease the risk of thrombus formation (option 3). If a valve is replaced with a
tissue valve, anticoagulation may be required during the immediate postoperativ
e period but is not necessarily lifelong. Therefore, the statements in options 1
and 4 cannot be correct. It is recommended to take antibiotics prior to dental
Strategy:
care
Cognitive
Client
Integrated
Content
(option
Need:
Area:
Level:
Remember
Process:
2).
Physiological
Adult
Analysis
that
Nursing
Health:
foreign
Integrity:
Process:
Cardiovascular
bodiesEvaluation
Reduction
in the vascular
of Risksystem
Potential
increase the risk
of thrombus LeMone,
References: formation. P., & Burke, K. (2008). <i>Medical-surgical nursing: Critica
l thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educati
on, pp.nurse
<Q>The
<TYPE>single</TYPE>
<P>
</P> 1060-1061.</F>
is caring for a client on the second postoperative day after corona
ry artery bypass (CABG) surgery. The client has a nursing diagnosis of <i>Impair
ed gas exchange</i>. Which action would the nurse take to best assist the client
<MC1>Assist
<MC2>Ensure
<MC3>Premedicate
<MC4>Auscultate
<F>Rationale:
<CORRECT>2</CORRECT>
with this diagnosis?</Q>
client
that
Atelectasis
lungs
client
withonce
deep
uses
before
isa the
breathing
shift.</MC4>
ambulation.</MC3>
incentive
number and
onespirometer
vigorous
complication
coughing
everyin the
hour.</MC2>
every
post-op
hour.</MC1>
CABG cli
ent. Hourly incentive spirometry and deep breathing are the preferred techniques
for lung expansion (option 2). Vigorous coughing (option 1) is discouraged for
post-CABG clients because it may increase intrathoracic pressure and cause insta
bility in the sternal area. Premedication before ambulation will facilitate acti
vity tolerance by reducing pain (option 3) but will not directly affect gas exch
ange. Auscultating lungs (option 4) will detect adventitious lung sounds resulti
ng from the ineffective breathing pattern, but it is an assessment, not an actio
n to encourage effective breathing. In addition, once a shift lung assessment is
Cognitive
Client
Integrated
Content
Strategy:
insufficient
Need:
Area:
Level:
Eliminate
Process:
Physiological
in Analysis
Adult
theall
Nursing
Health:
early
distracters
post-operative
Integrity:
Process:that
Cardiovascular
Planning
Reduction
are
period.
notofanRisk
intervention
Potentialor directly rel
ated to breathing.
Reference: LeMone, P., & Burke, K. (2008). <i>Medical-surgical nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, pp.client
<Q>A
<TYPE>single</TYPE>
<P>
</P> 980-982.</F>
who just underwent cardiac catheterization insists on getting up to
go to the bathroom to urinate immediately after returning to his room. Which of
the following
<MC1>"You can'twould
walkbeyet.
theYounurse's
may bebest
tooresponse?</Q>
weak after the procedure and may fall."
<MC2>"If you bend your leg, you will risk bleeding from the insertion site. It i
</MC1>
s an artery,
<MC3>"If you get
and out
it could
of bed,
leadyoutomay
complications."</MC2>
have an arrhythmia from the catheterization
. Your heart
<MC4>"The doctor
has has
to rest
ordered
afterthatthisyouprocedure."</MC3>
stay on bedrest for the next 6 hours. It i
s important that
<F>Rationale:
<CORRECT>2</CORRECT>
Bedrest
you follow
is prescribed
these orders."</MC4>
to allow the arterial puncture to seal and r
educe the risk of bleeding. Explaining the rationale to the client is the best w
ay to facilitate the client's cooperation (option 2). Although the other options
(1, 3, and 4) may be true statements, they do not address the need for the care
Cognitive
Client
Integrated
Content
Strategy:
restrictions
Need:
Area:
Level:
Integrate
Process:
Physiological
in Application
Adult
thisknowledge
Nursing
Health:
clientIntegrity:
Process:
Cardiovascular
atofthis
how the
time.
Implementation
Reduction
cardiacofcatheter
Risk Potential
is performed with home
ostasis. Recall that any vascular invasion requires time to allow for clot forma
Reference: Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). <i>Fundamentals
tion.
of nursing: concepts, process, and practice</i> (8th ed.). Upper Saddle River,
NJ: Pearson
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurseEducation,
is caring forpp. a271-272.</F>
client admitted to the Emergency Department (ED) wi
th chest pain. He reports that chest pain developed while mowing the lawn and he
stopped and rested on the sofa, as is typical for him. This time the pain was n
ot relieved by rest so he came to the ED. The chest pain is relieved following a
dministration of 2 sublingual nitroglycerine tablets. The nurse draws which conc
lusion abouthas
<MC1>Client
<MC2>Client most
thisalikely
client's
knowledge
hasstatus?</Q>
stable angina.</MC1>
deficit because he did not take his sublingual nitro
<MC3>Client most
glycerine.</MC2>
<MC4>Client
<F>Rationale:
<CORRECT>3</CORRECT>
Whenlikely
the character
has acute
unstable
ofmyocardial
chest
angina.</MC3>
paininfarction.</MC4>
changes or it is unrelieved by th
e usual measures (option 3) the client has unstable angina and is correct to go
to the ED. Stable angina (option 1) is described as chest pain that occurs in a
similar manner, with similar precipitating events, and is relieved with the same
intervention (either rest and/or nitroglycerine). There is no information that
indicates the client already has a current nitroglycerine prescription, and sinc
e the pain is usually relieved, he still should have come to the emergency room
(option 2). The chest pain associated with AMI is typically unrelieved by nitrog
lycerineNeed:
Cognitive
Client
Integrated
Content
Strategy:Area:
orDefine
Level:
Process:
rest
Physiological
Adult
andHealth:
Analysis
the Nursing
usuallyof
types Integrity:
Process:
Cardiovascular
requires
angina and
Planning
morphine
Physiological
determine
(option
which
Adaptation
4).type of angina is repre
sented in the question. Note that association between the changing nature of the
Reference:
client's pattern
LeMone,ofP.,pain
& Burke,
and theK.word
(2008).
<i>unstable</i>
<i>Medical-surgical
in the correct
nursing:option.
Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 987.</F>
<Q>The
<TYPE>single</TYPE>
<P>
</P> nurse is assessing a client at 07:30 in the morning on a day when the cli
ent has a cardiac stress test scheduled for 11:30. The client reports that no br
eakfast was delivered this morning and the client is hungry. Which of the follow
ing is the client
<MC1>Bring
<MC2>Explain nurse's
that client
coffee
best action?</Q>
and toast.</MC1>
should have no food the morning of a cardiac stress tes
<MC3>Call nutrition department and get the client's regular full breakfast.</MC3
t.</MC2>
><MC4>Have nursing assistant get the client cereal with milk and orange juice.</M
<F>Rationale: The client should have a light meal with no caffeine before a card
<CORRECT>4</CORRECT>
C4>
iac stress test (option 4) and should refrain from eating or drinking for 2 to 3
hours before the test. Options 2 and 3 are incorrect because they do not follow
this guideline. Caffeine (option 1) may cause sympathetic nervous system stimul
ation resulting in an increase in heart rate and blood pressure. This could make
Cognitive
Client
Integrated
Content
Strategy:
the results
Need:
Area:
Level:
Recall
Process:
ofAdult
Physiological
the
Application
thattest
Nursing
Health:
a stress
difficult
Integrity:
Process:
Cardiovascular
testtoevaluates
Implementation
determine.
Reduction theofcardiac
Risk Potential
circulation in relatio
n to cardiac workload. Select the distracter that minimizes cardiac workload but
Reference:
prevents the
LeMone,
clientP.,from
& Burke,
becoming
K. (2008).
weak or <i>Medical-surgical
dehydrated prior to nursing:
the test.Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p.hospitalized
<Q>A
<TYPE>single</TYPE>
<P>
</P> 944.</F> client has continuous electrocardiographic (ECG) monitoring, a
nd the monitor shows that the rhythm has suddenly changed to ventricular tachyca
rdia (VT). What
<MC1>Administer
<MC2>Obtain
<MC3>Quickly the
assess
is the
intravenous
defibrillator
thefirst
client's
lidocaine
action
andlevel
defibrillate
that
according
ofthe
consciousness,
nurse
the
to client.</MC2>
shouldblood
emergency
take?</Q>
protocol.</MC1>
pressure, and pul
<MC4>AdministerThea best
se.</MC3>
<F>Rationale:
<CORRECT>3</CORRECT> precordial
first action
thump.</MC4>
is to assess the client's level of conscious
ness and assess if the VT is perfusing the body by measuring the BP and pulse (o
ption 3). If the client is in a pulseless ventricular tachycardia, immediate def
ibrillation (option 2) is performed by an ACLS certified nurse. If the client ha
s a good BP and pulse and is awake and alert, the nurse may administer intraveno
us lidocaine (option 1) as ordered. A precordial thump (option 4) may be effecti
ve in converting a witnessed VT to a normal rhythm but will only be performed af
ter assessing
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
First,
Process:
Safe
therecall
Adult
Analysis
client.
Effective
Nursing
Health:
thatCardiovascular
Care
Process:
thereEnvironment:
arePlanning
two formsManagement
of presentation
of Care with VT and the
underlying perfusion to the brain and vital organs is a key differentiating fac
tor. Recall that assessment always precedes intervention to make the correct sel
ection aboutBerman,
Reference: how toA.,proceed
Snyder,
withS.,decision
Kozier,making.
B., & Erb, G. (2008). <i>Fundamentals
of nursing: Concepts, process, and practice</i> (8th ed.). Upper Saddle River,
NJ: Pearson
<Q>The
<TYPE>single</TYPE>
<P>
</P> physician
Education,
has diagnosed
pp. 175-177.</F>
acute myocardial infarction (AMI) on the basis of
electrocardiogram (ECG) changes for a client in the Emergency Department (ED).
The nurse assesses the client frequently, and notes that the client seems forget
ful, and periodically asks the nurse to explain the ECG and noninvasive blood pr
essure monitors. The nurse concludes that the client's response is most likely d
ue to which in
<MC1>Client
<MC2>Client
<MC3>Nurses of the
is showing
following
emergency
signs room
reasons?</Q>
of very
fear
areand
early
tooanxiety.</MC2>
busy
Alzheimer's
to properly
disease.</MC1>
explain the purpose o
f equipment.</MC3>
<MC4>Memory lapses are common with clients experiencing myocardial infarctions.<
<F>Rationale: Anxiety and fear are common responses to a diagnosis of myocardial
<CORRECT>2</CORRECT>
/MC4>
infarction because of the possibility of death (option 2). This prevents the cl
ient and family from absorbing the detailed explanations about the care being pr
ovided. Memory lapses are not a common symptom of myocardial infarction (option
4). There is not adequate information to determine that this memory lapse is ass
ociated with Alzheimer's disease (option 1), and this would not be the best time
to make that determination. Nurses in the ED are able to explain procedures wel
l to their
Cognitive
Client
Integrated
Content
Strategy:
Need:
Area:
Level:
To
clients
Process:
Psychosocial
select
Adult
Analysis
(option
Nursing
Health:
the correct
Integrity
3).
Process:
Cardiovascular
distracter,
Analysisunderstand the typical response to a
nd acute myocardial
Reference: LeMone, P., infarction
& Burke,andK. (2008).
the effects
<i>Medical-surgical
of anxiety. nursing: Critical
thinking in client care</i> (4th ed.). Upper Saddle River, NJ: Pearson Educatio
n, p. 993.</F>
</P>