170 Nursezone Medical-surgical Nursing Application Exam Part 2 (76 To 100)

The correct answer is Morphine because it is the drug of choice to control pain associated with myocardial infarction. Morphine is an opioid analgesic that acts on the central nervous system to relieve pain and reduce anxiety. It is commonly used in emergency situations to manage severe pain, such as the midsternal pain experienced by the client in this case. Morphine is effective in reducing pain and improving blood flow to the heart, making it an appropriate choice for this client.

During the early postoperative period after open heart surgery, adequate oxygenation is crucial because hypoxia, or low oxygen levels, can stimulate dangerous dysrhythmias. Dysrhythmias are abnormal heart rhythms that can be life-threatening. When the heart does not receive enough oxygen, it can lead to irregular electrical signals and disrupt the normal rhythm of the heart. Therefore, ensuring sufficient oxygen supply is essential to prevent the occurrence of dysrhythmias and promote the patient's recovery after open heart surgery.

The correct answer is to inform the patient about the new medication, including its name, use, and reason for the change. This is important because the patient has the right to know what medication they are being given and why it is being prescribed to them. It is also important to provide this information so that the patient can give informed consent and understand any potential side effects or interactions with other medications they may be taking.

The most important element of the smoking history for this assessment is the number of pack years. This information helps to determine the extent of smoking exposure and the potential damage it may have caused to the client's coronary arteries. It provides a better understanding of the client's risk for coronary artery disease and helps in planning appropriate treatment and interventions.

After cardiac catheterization, it is important for the nurse to monitor the client's apical pulse and blood pressure frequently. This is because the client, Mr. Toni, is experiencing a crushing chest pain and is anxious. Monitoring the apical pulse and blood pressure can help assess the client's cardiovascular status and detect any abnormalities or changes that may require immediate intervention. This is especially important in the case of Mr. Toni, who is a chronic smoker and alcoholic, as these factors can increase the risk of cardiovascular complications.

The correct answer is palpating for diminished or absent peripheral pulses. This is because Reynaud's disease is a condition that affects the blood vessels, causing them to narrow and restrict blood flow to the extremities. Palpating for diminished or absent peripheral pulses can indicate poor circulation in the affected areas, which is a common symptom of Reynaud's disease. Checking for a rash on the digits, palpating for a rapid or irregular peripheral pulse, and observing for softening of the nails or nail beds are not specifically associated with Reynaud's disease.

The nurse's priority is to take the blood pressure in the other arm and then schedule a physician's appointment for the client as soon as possible. This is because the client's blood pressure readings of 172/104 and 164/98 are significantly elevated and indicate hypertension. Taking the blood pressure in the other arm will help confirm the accuracy of the readings. Scheduling a physician's appointment is important to further assess the client's condition and determine the appropriate course of treatment.

The correct answer is bleeding at the arterial puncture site. After cardiac catheterization, it is important for the patient to remain in a supine position with the affected leg straight for 6 hours. This helps to prevent bleeding at the arterial puncture site, as the pressure from the body weight helps to compress the site and promote clotting. Additionally, keeping the leg straight helps to prevent movement or bending at the puncture site, which could disrupt the clotting process and lead to bleeding.

The client will be advised to be NPO (nothing by mouth) for 6 to 8 hours before the cardiac catheterization procedure. This is important because the procedure involves inserting a catheter into the blood vessels to examine the heart, and it is necessary for the client to have an empty stomach to reduce the risk of complications such as aspiration.

Based on the given information, the client is homeless and has large irregularly shaped ulcers located in the lower outer leg with a beefy red base. These characteristics are consistent with venous stasis ulcers. Venous stasis ulcers are typically caused by poor blood circulation due to venous insufficiency, which can be a result of long periods of standing or sitting, obesity, or deep vein thrombosis. In this case, the ulcers are likely caused by the client's homeless situation and lack of access to proper healthcare and hygiene, leading to poor blood circulation and the development of venous stasis ulcers.

The correct answer is to review the intake and output records for the last 2 days. Edema in the lower extremities can be a sign of fluid retention, which is common in patients with myocardial infarction. By reviewing the intake and output records, the nurse can assess the fluid balance of the patient and determine if there has been an increase in fluid intake or a decrease in fluid output. This information can help guide further interventions, such as adjusting diuretic therapy or implementing a sodium restriction if necessary.

The correct answer is MB. In the context of a suspected myocardial infarction, Nurse Flora would assess for elevations in isoenzyme values reported with the creatinine kinase (CK) level. CK-MB is a specific isoenzyme of CK that is found predominantly in the heart muscle. An elevated CK-MB level indicates damage to the heart muscle, which is consistent with a myocardial infarction. Therefore, assessing for elevations in the MB isoenzyme is important in diagnosing and managing a suspected heart attack.

Nurse Gemma would expect the first heart sound (S1) to be the loudest at the apex of the heart. The apex is the lower tip of the heart and is located at the left side of the chest. This is where the mitral valve is located, which is responsible for producing the S1 sound. The sound is louder at the apex because the mitral valve is closer to the chest wall in this area.

The correct answer is "Bathroom privileges and self-care activities." This is because the client has been transferred to a general medical unit with cardiac monitoring, indicating that their condition is stable and they can engage in activities such as using the bathroom and taking care of themselves. The other options, such as strict bed rest or unsupervised hallway ambulation, may not be appropriate for a client with a suspected myocardial infarction.

The correct answer is "I always clean my stump with mild soap, and I make sure that I put some alcohol in it before I put my stump socks." This statement indicates a lack of understanding about stump care because cleaning the stump with alcohol can be too harsh and drying, which can lead to redness and blistering. Mild soap and water should be used instead.

Premature beats followed by a compensatory pause indicate the presence of premature ventricular contractions (PVCs). In this situation, Mr. Toni is at risk for PVCs due to his age, smoking, and alcohol consumption. PVCs are extra, abnormal heartbeats that originate in the ventricles instead of the normal heart's electrical system. They can cause a feeling of skipped or extra beats and may be accompanied by chest pain. The compensatory pause occurs after the premature beat to allow the heart to reset before the next normal beat. This pattern can be detected by assessing the client's heart rhythm using cardiac monitoring leads.

The correct answer is to compare the femoral, popliteal, and pedal pulses in both legs. This is the priority intervention because the patient is experiencing tingling sensations in the affected leg after cardiac catheterization. Comparing the pulses in both legs will help determine if there is adequate blood flow to the affected leg and if there is a potential complication such as a blockage or clot. This assessment is crucial in identifying any vascular compromise and ensuring prompt intervention to prevent further complications.

The client being a male American who grew in the Philippines is not a modifiable risk factor for hypertension. Modifiable risk factors are those that can be changed or controlled, such as diet, physical activity, and stress levels. Being a male or the client's nationality and place of growth are not factors that can be modified to reduce the risk of hypertension.

The patient's blood pressure reading of 105/86 mmHg, edema grade of 1 compared to the baseline which is grade 3, and potassium level of 4.5 mEq/L indicate effectiveness of the medication. However, tenting of the skin when pinched gently is not a relevant assessment for the effectiveness of hydrochlorothiazide in treating hypertension.

Based on the given information, Mr. Baker is diagnosed with hypercholesterolemia, which is an elevated level of cholesterol in the blood. Diabetes mellitus is a major risk factor for Coronary Artery Disease (CAD) because it can lead to the development of atherosclerosis, a condition where the arteries become narrowed and hardened due to the buildup of plaque. This can increase the risk of CAD, as it restricts blood flow to the heart. Therefore, the nurse should assess for a history of diabetes mellitus as a potential risk factor for CAD in Mr. Baker.

Cardiac catheterization is not performed to differentiate ischemia from dilated cardiomyopathy. It is a procedure used to obtain a clear picture of cardiac anatomy before heart surgery, obtain pressures within the heart chambers and the great vessels, and obtain endocardial biopsy specimens. Ischemia and dilated cardiomyopathy are typically diagnosed through other methods such as electrocardiogram (ECG), echocardiogram, and cardiac MRI.

The statement "The pain occurred after my meal" is most suggestive of angina pectoris because angina is chest pain or discomfort that occurs when the heart muscle does not receive enough blood. This lack of blood flow to the heart muscle can be triggered by physical exertion or emotional stress, but it can also be triggered by a heavy meal. Therefore, experiencing chest pain after a meal could indicate that the pain is related to angina pectoris.

The given answer is incorrect because it does not address the client's coping mechanism or provide any support or intervention related to the client's body image and self-esteem. The nurse should focus on listening to the client, comforting any misconceptions, arranging for the client to meet with an amputee, and discussing the advantages of prosthetics to help the client cope with the change in body image.

The correct answer is 2, 3, 4. These interventions are appropriate for a client with deep vein thrombosis. Encouraging increased oral intake of water helps prevent dehydration, which can contribute to blood clot formation. Encouraging coughing with deep breathing helps prevent the pooling of blood in the lower extremities and promotes circulation. Placing thigh-length elastic stockings on the client helps promote venous return and prevent blood clot formation. Placing the client in Fowler's position for eating is not specifically related to preventing deep vein thrombosis. Encouraging the intake of dark, green leafy vegetables is not directly related to preventing deep vein thrombosis. Placing sequential compression boots on the client is not mentioned as an appropriate intervention for preventing deep vein thrombosis.

The correct answer is "I drink one to two glasses of water before drinking an alcoholic beverage." This statement demonstrates understanding of the teaching regarding calorie-restriction diet because it shows awareness of the importance of hydration and making healthier choices when consuming alcoholic beverages. Drinking water before drinking alcohol can help to prevent overconsumption and dehydration, which can be beneficial for someone following a calorie-restriction diet.