MS FINALS

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Questions and Answers

Where should the nurse locate the apical pulse on a patient with a normal heart position?

  • Left second intercostal space at the midclavicular line (correct)
  • Left fifth intercostal space at the midclavicular line (correct)
  • Right third intercostal space at the midclavicular line
  • Right second intercostal space at the midclavicular line

A patient's heart rate is 140 bpm. Which complication should the nurse closely monitor for?

  • Right-sided heart failure
  • A stroke
  • Myocardial ischemia (correct)
  • A pulmonary embolism

A patient is experiencing frequent episodes of ventricular fibrillation. Which device is most appropriate for sensing and terminating these episodes?

  • Implantable cardioverter defibrillator (ICD) (correct)
  • Atropine
  • Pacemaker
  • Epinephrine

Which medication would the nurse administer to decrease automaticity in a patient with a rapid heart rate?

<p>Metoprolol (C)</p> Signup and view all the answers

A patient has a heart rate of 72 bpm with a regular rhythm. Which area is the impulse likely originating from?

<p>sinoatrial node (B)</p> Signup and view all the answers

The nurse is assessing a patient with a permanent pacemaker. Which parameter related to the pacemaker should the nurse document?

<p>Pacer rate (D)</p> Signup and view all the answers

During which phase of the cardiac action potential does the nurse identify as the resting phase before the next depolarization?

<p>Phase 4 (B)</p> Signup and view all the answers

An echocardiogram reveals an ejection fraction of 35%. The nurse anticipates treatment for which condition?

<p>Heart failure (B)</p> Signup and view all the answers

The nurse observes a patient with a first-degree AV block on the monitor. Which characteristic would the nurse expect to see?

<p>Delayed conduction, producing a prolonged PR interval (C)</p> Signup and view all the answers

A patient is experiencing a rapid, disorganized ventricular rhythm with no pulse. Which rhythm is the patient likely experiencing?

<p>Ventricular fibrillation (B)</p> Signup and view all the answers

Which nonmodifiable risk factor for atherosclerosis should the nurse educate a patient about?

<p>Positive family history (D)</p> Signup and view all the answers

Which of these is the first action a nurse should take when a patient presents with ventricular fibrillation?

<p>Begin cardiopulmonary resuscitation (CPR) (B)</p> Signup and view all the answers

When assessing a patient's blood pressure, what does the nurse document as the difference between the systolic and diastolic pressures?

<p>Pulse pressure (B)</p> Signup and view all the answers

When defibrillating a patient with a monophasic defibrillator, what amount of paddle pressure should the nurse apply?

<p>15 to 20 lb (C)</p> Signup and view all the answers

Which of these instructions is NOT appropriate for a patient who has had an ICD inserted?

<p>The patient may have a throbbing pain that is normal (D)</p> Signup and view all the answers

A patient recovering from cardiac surgery exhibits peaked T waves, extremity paresthesia, and mental confusion. Which electrolyte imbalance should the nurse prioritize assessing for?

<p>Potassium (A)</p> Signup and view all the answers

After cardiac surgery, a patient develops signs of cardiac failure. Which nursing action would be most crucial in managing this complication?

<p>Administering furosemide (A)</p> Signup and view all the answers

A patient presents with shortness of breath, lightheadedness, fatigue, and a systolic click during auscultation. Which valvular disorder is most likely based on these findings?

<p>Mitral valve prolapse (B)</p> Signup and view all the answers

Which of the following complications should the nurse monitor for in a patient who has recently undergone cardiac surgery? (Select all that apply)

<p>Abrupt closure of the artery (A), Coronary artery vasospasm (C), Aortic dissection (D), Arterial dissection (E)</p> Signup and view all the answers

A patient with mitral stenosis exhibits a weak and irregular pulse rhythm. Which rhythm is most likely identified on the electrocardiogram (ECG)?

<p>Atrial fibrillation (C)</p> Signup and view all the answers

A murmur is auscultated during a patient's assessment, which strongly suggests a mitral valve regurgitation. What characteristics describe this murmur?

<p>High-pitched holosystolic murmur at the apex (B)</p> Signup and view all the answers

A patient who is being educated about mitral valve prolapse expresses understanding of the care requirements. Which statement demonstrates their understanding?

<p>I will take antibiotics before getting my teeth cleaned (D)</p> Signup and view all the answers

A patient in the intensive care unit (ICU) after cardiac surgery is being monitored for complications. Which of the following complications is directly associated with altered preload?

<p>Cardiac tamponade (B)</p> Signup and view all the answers

During an angiography, a patient experiences nausea and difficulty breathing after contrast administration. What is the priority medication to administer?

<p>Epinephrine (C)</p> Signup and view all the answers

A patient with peripheral arterial disease is ambulating in the hallway. What instruction should the nurse provide regarding pain management during ambulation?

<p>Walk to the point of pain, rest until the pain subsides, then resume ambulation. (B)</p> Signup and view all the answers

A patient, 2 days post-operatively, presents with pain in the left lower extremity and a 2 cm difference in circumference between the right and left leg. What nursing intervention promotes arterial flow in this scenario?

<p>Assist with active range of motion (ROM) exercises to the left lower extremity. (B)</p> Signup and view all the answers

What therapeutic range of the international normalized ratio (INR) indicates effective anticoagulation therapy?

<p>2.0 to 3.0 (A)</p> Signup and view all the answers

When does therapeutic benefit from warfarin therapy typically begin?

<p>In 3 to 5 days (C)</p> Signup and view all the answers

What lower extremity assessment finding is characteristic of venous insufficiency?

<p>Ulceration (D)</p> Signup and view all the answers

What education should the nurse provide to a patient with chronic venous insufficiency to prevent complications? (Select all that apply.)

<p>Avoid constricting garments. (A), Elevate the legs above the heart level for 30 minutes every 2 hours. (C), Wear compression stockings as prescribed. (D)</p> Signup and view all the answers

What is the primary reason for administering a diuretic to a patient with deep vein obstruction?

<p>To decrease edema and promote venous return. (C)</p> Signup and view all the answers

Which of the following medications would the nurse have at the bedside prior to administering injected allergens for "hyposensitization" to prevent potential systemic reactions?

<p>Epinephrine (D)</p> Signup and view all the answers

A patient has been diagnosed with an allergy to peanuts. Which of the following is a priority for this patient to carry at all times to manage a potential allergic reaction?

<p>An EpiPen (A)</p> Signup and view all the answers

A patient is using Afrin nasal spray for a "stuffy nose." What education should the nurse provide to prevent "rebound congestion"?

<p>Only use the Afrin for 3 to 4 days once every 12 hours. (C)</p> Signup and view all the answers

Which of the following statements accurately reflects the nurse's best response to a patient who reports that their corticosteroid nasal spray for allergic rhinitis is not working after 3 days?

<p>The full benefit of the medication may take up to 2 weeks to be achieved. (D)</p> Signup and view all the answers

A patient is taking long-term corticosteroids. Which of the following education points should the nurse prioritize?

<p>The patient should not stop taking the medication abruptly and should be weaned off the medication. (A)</p> Signup and view all the answers

Which of the following medications is most likely responsible for a severe angioedema reaction that occurs shortly after taking a new antihypertensive medication?

<p>Angiotensin-converting enzyme (ACE) inhibitor (C)</p> Signup and view all the answers

The nurse is preparing to administer a medication. Which of the following areas of concern would the nurse consider when the medication is known to constrict integumentary smooth muscle?

<p>Risk of skin flushing and itching (D)</p> Signup and view all the answers

A patient is receiving a medication that causes bronchodilation. Which of the following symptoms would the nurse monitor for as a potential adverse effect?

<p>Increased wheezing and shortness of breath (C)</p> Signup and view all the answers

A patient with type 1 diabetes is experiencing frequent episodes of hypoglycemia. What is the most likely reason for this?

<p>The patient is taking too much insulin. (A)</p> Signup and view all the answers

A patient with type 2 diabetes is experiencing significant weight gain despite adhering to a calorie-restricted diet. Which factor is MOST likely contributing to their weight gain?

<p>Increased insulin resistance. (D)</p> Signup and view all the answers

A patient with diabetes is experiencing frequent episodes of hyperglycemia. Which intervention should the nurse prioritize?

<p>Administering rapid-acting insulin. (A)</p> Signup and view all the answers

A patient with type 1 diabetes presents to the emergency department with diabetic ketoacidosis. Which of the following laboratory values is MOST consistent with this diagnosis?

<p>Blood glucose of 800 mg/dL, pH of 7.15. (D)</p> Signup and view all the answers

The nurse is assessing a patient with diabetic neuropathy. Which of the following symptoms is the nurse MOST likely to observe?

<p>Loss of sensation in the extremities. (B)</p> Signup and view all the answers

A patient with type 1 diabetes is admitted to the hospital for the management of hyperglycemia. Which of the following nursing interventions is MOST appropriate in this situation?

<p>Monitoring the patient's blood glucose levels frequently. (A)</p> Signup and view all the answers

The nurse is teaching a patient with diabetes about foot care. Which instruction should the nurse prioritize?

<p>Inspect feet daily for any signs of injury or infection. (D)</p> Signup and view all the answers

A patient with diabetes is being discharged home after hospitalization for hyperglycemia. Which of the following discharge instructions should the nurse include?

<p>Contact the healthcare provider if blood glucose levels are consistently high. (B)</p> Signup and view all the answers

Flashcards

Apical pulse location

The apical pulse is usually located at the left fifth intercostal space at the midclavicular line.

Normal heart rate complication

A heart rate of 140 bpm can lead to complications like myocardial ischemia.

Beta-blocker example

Metoprolol is a beta-blocker that decreases heart automaticity.

Impulse origin at 72 bpm

The impulse arises from the sinoatrial node in a heart with a rate of 72 bpm.

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Resting phase of ECG

Phase 4 is the resting phase before the next depolarization in an ECG.

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Ejection fraction 35%

An ejection fraction of 35% indicates potential heart failure.

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Pulse pressure definition

Pulse pressure is the difference between systolic and diastolic blood pressures.

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Effect of small BP cuff

Using a cuff that is too small can result in falsely high blood pressure readings.

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First action by nurse in cardiac arrest

Begin cardiopulmonary resuscitation (CPR) immediately.

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Defibrillation paddle pressure

The nurse should apply 10 to 15 lb of pressure when defibrillating.

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Best device for ventricular fibrillation

An Implantable Cardioverter Defibrillator (ICD) is best for sensing and terminating ventricular fibrillation episodes.

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First-degree AV block characteristic

Delayed conduction evident by a prolonged PR interval.

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Pacemaker documentation

Document the date and time of insertion, location of the generator, model number, and pacer rate.

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Post-ICD patient education

Educate to avoid magnetic fields, call for dizziness, record shock sensations, and normal pain sensations.

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Continuous hiccups after pacemaker insertion

Continuous hiccups may indicate lead wire dislodgement.

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Rhythm in unresponsive patient post-MI

Rapid, disorganized ventricular rhythm indicates ventricular fibrillation.

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Complications after cardiac surgery

Potential risks the nurse must monitor for following surgery, including artery issues and nerve pressure.

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Electrolyte imbalance signs

Symptoms such as paresthesia, peaked T waves, indicating an electrolyte disturbance, primarily potassium.

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Preload alterations

Changes in preload can lead to complications; one common issue is cardiac tamponade.

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Cardiac failure interventions

Actions like administering furosemide, digoxin, or milrinone for managing cardiac failure after CABG.

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Mitral valve prolapse symptoms

Signs include shortness of breath, lightheadedness, and systolic clicks indicating possible valve issues.

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Patient education on mitral valve prolapse

Patients should avoid caffeine, alcohol, smoking to manage their condition effectively.

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Heart rhythm assessment in mitral stenosis

Mitral stenosis may present with an irregular pulse rhythm like atrial fibrillation on ECG.

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Murmur types in mitral valve regurgitation

A high-pitched blowing sound at the apex correlates with mitral valve regurgitation.

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Angiography complications

Nausea and difficulty breathing after contrast administration.

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Priority medication for allergies

Epinephrine is given to treat severe allergic reactions.

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Peripheral arterial disease education

Patients should walk to the point of pain, rest, and then resume walking.

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Deep vein obstruction assessment

Check for leg pain and swelling differences between limbs.

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Therapeutic INR range

An INR of 2.0 to 3.0 indicates effective anticoagulant therapy.

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Onset of warfarin therapy benefits

Therapeutic effects begin in 3 to 5 days after starting warfarin.

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Assessment for venous insufficiency

Assess for signs like rubor, cellulitis, dermatitis, and ulceration.

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Venous insufficiency prevention

Advise patients to elevate legs and avoid constricting garments.

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Tricyclic antidepressants and SIADH

Monitor strict intake and output for SIADH patients on tricyclic antidepressants.

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Clinical characteristics of type 1 diabetes

Type 1 diabetes is often associated with ketosis, little endogenous insulin, and younger age at diagnosis.

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Priority monitoring in type 1 diabetes

Hypoglycemia is the most critical clinical manifestation to monitor in type 1 diabetes.

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Daily caloric intake for weight loss

To lose weight, a 130 lb woman with an ideal weight of 116 lb should consume around 1200 calories daily for 2 lb/week weight loss.

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Intermediate-acting insulin

NPH is the standard intermediate-acting insulin administered to diabetic patients.

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Decreased temperature sensation in diabetes

Autonomic neuropathy often leads to decreased temperature sensation in patients with diabetes.

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Hypoglycemia glucose levels

Hypoglycemia is classified as a glucose level lower than 50 to 60 mg/dL.

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Complications of rehydration in DKA

After rehydration in DKA, monitor for hypokalemia as a potential complication.

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Bronchodilation

The expansion of air passages in the lungs, improving airflow.

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Laryngospasm

A sudden spasm of the vocal cords, causing difficulty in breathing or speaking.

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Angioedema

Swelling beneath the skin, often in response to allergies; can be life-threatening.

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EpiPen

A device for injecting epinephrine during severe allergic reactions.

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Corticosteroid nasal spray

A medication used to relieve nasal inflammation and congestion from allergies.

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Rebound congestion

Worsening nasal congestion after prolonged use of decongestant sprays.

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Hyposensitization

Treatment technique using allergens to decrease sensitivity and reactions.

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Long-term corticosteroid education

Patients must be weaned off corticosteroids, avoiding abrupt cessation.

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Study Notes

CARDIOVASCULAR SYSTEM

  • The heart is a hollow, muscular organ located in the center of the thorax.
  • It occupies the space between the lungs (mediastinum) and rests on the diaphragm.
  • The heart has three layers:
    • Endocardium: The inner layer, consisting of endothelial tissue.
    • Myocardium: The middle layer, composed of muscle fibers responsible for pumping action.
    • Epicardium: The outer layer.
  • The pericardium is a thin, fibrous sac that encases the heart.
  • The heart has four chambers: two atria (top chambers) and two ventricles (bottom chambers).
  • The heart has four valves: two atrioventricular (AV) valves and two semilunar valves.
    • AV valves: Separate the atria from the ventricles.
    • Semilunar valves: Shaped like half-moons, and prevent backflow.
  • Coronary arteries supply oxygenated blood to the heart muscle.
  • Myocardium is the middle muscular layer of the atria and ventricular walls.
  • ECG readings record the electrical activity of the heart.
  • The sinoatrial node is located in the junction of the superior vena cava and the right atrium.
  • Parietal Pericardium supports the heart in the mediastinum.

Situational Questions (Chapter 21)

  • Question 1: Pericarditis inflammation is located in the thin fibrous sac encasing the heart.
  • Question 2: An abnormal heart sound detected early in diastole is documented as S3.
  • Question 3: The apical pulse is located in the left fifth intercostal space at the midclavicular line, in a normal heart position.
  • Question 4: A patient's heart rate of 140 bpm requires monitoring for complications such as myocardial ischemia, pulmonary embolism, or right-sided heart failure.
  • Beta-blockers are used to decrease automaticity.
  • Metoprolol is a beta-blocker.
  • Atrial fibrillation is a condition characterized by an irregular heart rhythm.
  • Warfarin is used to prevent complications of atrial thrombi.
  • CPR is an initial response for patients without a pulse.

Electrocardiogram (ECG)

  • The ECG displays the electrical activity of the heart.
  • Phase 4 is the resting phase before the next depolarization.

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