Coronary Artery Disease

Coronary artery disease (CAD) affects the arteries. When narrowing of the coronary arteries (the large arteries that supply the myocardium with blood) occurs, the result is ischemia. Narrowing of the coronary arteries is usually due to atherosclerosis.

Atherosclerosis and Arteriosclerosis

Though atherosclerosis and arteriosclerosis are related problems, they are not the same. Atherosclerosis is a type of arteriosclerosis involving cholesterol deposits and triglyceride deposits. Atherosclerosis is the overgrowth of smooth muscle cells. Narrowing of the blood vessels is the result of an overgrowth of intimal smooth muscle cells. This narrowing causes decreased blood flow to the heart and major organs. Arteriosclerosis is the thic ening and hardening of the arterial walls. !ymptoms of arteriosclerosis and atherosclerosis include intermittent claudication, decreased circulation to the e"tremities, changes in s in color and coolness of the e"tremities, headaches, di##iness, and loss of memory. $actors that contribute to arteriosclerosis and atherosclerosis are age, obesity, cigarette smo ing, diabetes, and familial predisposition. Treatment of systemic signs of arteriosclerosis involves weight control with a diet low in fats and cholesterol. !tress reduction and smo ing cessation also help to decrease the client%s ris factors.

Conduction System of the Heart

The normal conduction system of the heart is composed of the sinoatrial (!A) node located at the junction of the right atrium and the superior vena cava. The !A node is the main pacer of the heart rate. This area contains the pacing cells that initiate the contraction of the heart. The atrioventricular (A&) node is located in the interventricular septum. The A& node receives the impulse and transmits it to the bundle of 'is, which e"tends down through the ventricular septum and merges with the (ur inje fibers in the lower portion of the ventricles. $igure ).* shows an anatomical drawing of the conduction system of the human heart.

FIGURE 3.2 +lectrical system of the heart.

Heart

loc!

'eart bloc can occur as the result of structural changes in the conduction system (such as myocardial infarctions, coronary artery disease, tumors, and infections of the heart) or to"ic effects of drugs (such as digitalis). $irst,degree A& bloc occurs when the !A node continues to function normally but transmission of the impulse is slowed. -ecause of the conduction dysfunction and

ventricular depolari#ation, the heart beats regularly but the (,. interval is slowed. These clients are usually asymptomatic, and all impulses eventually reach the ventricles. !econd,degree heart bloc is a bloc in which some impulses reach the ventricles but others do not. /n third,degree heart bloc or complete heart block, none of the sinus impulses reach the ventricle. This results in erratic heart rates in which the sinus node and the atrioventricular nodes beat independently. The result of this type of heart bloc can be hypotension, sei#ures, cerebral ischemia, or cardiac arrest. A heart bloc is detected by assessing an electrocardiogram as illustrated in $igure ).).

FIGURE 3.3 'eart -loc

"o#icity to $edications
To"icity to medications such as calcium chanel bloc ers, betabloc ers, or digitalis can be associated with heart bloc . 0lients ta ing betabloc ers or digo"in (1igitalis) should be taught to chec their pulse rate and to return to their physician for regular evaluations of their digitalis levels. 2udicious monitoring of the digo"in (1igitalis) blood levels is an important factor in the care of the client. The therapeutic level for digo"in (1igitalis) is 3.456.* ng7m8. /f the client%s blood level of digo"in (1igitalis) e"ceeds *.3 ng7m8, the client is considered to"ic. 0lients with digo"in to"icity often complain of nausea, vomiting, and seeing halos around lights. A resting pulse rate of less than 93 bpm in an adult client, less than :3 bpm in a child, and less than 633 bpm in a neonatal client should alert the nurse to the possibility of to"icity. Treatment for digitalis to"icity includes chec ing the potassium level because hypo alemia can contribute to digitalis to"icity. The physician often will order potassium be given /& or orally and that the

digitalis be held until serum levels return to normal. Another medication, such as /suprel or atropine, is fre;uently ordered to increase the heart rate. A high,fiber diet will also be ordered because constipation contributes to digitalis to"icity.

$alfunction of the Conduction System

-ecause a malfunction of the conduction system of the heart is the most common cause of heart bloc , a pacing mechanism is fre;uently implanted to facilitate conduction. (acema ers can be permanent or temporary and categori#ed as demand or set. A demand pacema er initiates an impulse if the client%s heart rate falls below the prescribed beats per minute. A set pacema er overrides the heart%s own conduction system and delivers an impulse at the rate set by the physician. (acema ers can be combined with an internal defibrillation device. $igure ).< shows a graph that depicts a pacema er spi e with a normal +0=.

FIGURE 3.% /ndicates the pacema er spi e with a normal +0=.

Cardiac Dysrhythmias
0ardiac dysrhythmias occur when the heart loses its regular pacing capability. They are classified according to their origins. These abnormal rhythms can be lethal or of no danger to the client%s well,being. Tachydysrhythmias are characteri#ed by a heart rate greater than 633 bpm. /f the client has coronary artery disease, blood flow to the heart might be decreased. Bradydysrhythmias are characteri#ed by a heart rate less than 93 beats per minute. 1i##iness and syncopy are often the only symptoms the client notices. The client might tolerate this slow rate, or bradydysrhythmias might cause the blood pressure to be subnormal, leading to shoc or ischemia. Another alteration in the normal beat the client might e"perience is bigeminy, a condition in which arrhythmias occur in pairs. The pairs can be junctional, atrial, or ventricular beats. A junctional beat is one originating at the A& and bundle of 'is. An atrial dysrhythmia originates in the atria of the heart, while a ventricular dysrhythmia originates in the ventricle of the heart. !ee Table ).6 for characteristics and treatment of atrial dysrthymias.

"A &E 3.' Su(ra)entricular Rhythm Characteristics >nli e tachydysrhythmias and bradydysrhythmias, which usually originate in the atria, ventricular dysrhythmias are life,threatening and their impulses originate in the ventricles.

*entricular "achycardia
&entricular rhythms are those originating in the ventricle. These rhythms can result in

decreased o"ygen perfusion to the body and possible death. !ee Table ).* for the characteristics and treatment of ventricular rhythms.

"A &E 3.2 *entricular Rhythm Characteristics -ecause ventricular tachycardia is lethal, the item writers for +C&E, might as the student to identify an +0= rhythm. /t should be noted that ventricular tachycardia is a rapid irregular rhythm with the absence of a ( wave. The rate can be *?3 bpm, and the !A node continues to discharge independently of the ventricle. &entricular tachycardia is often associated with valvular heart disease, heart failure, hypomagnesium, hypotension, and ventricular aneurysms. $igure ).@ shows an +0= reading indicative of ventricular tachycardia.

FIGURE 3.- +vidence of ventricular tachycardia.

*entricular Fi.rillation
Ventricular fibrillation (V-fib) s the primary mechanism associated with sudden cardiac arrest. This disorgani#ed chaotic rhythm results in a lac of pumping activity of the heart. Without effective pumping, no o"ygen is sent to the brain and other vital organs. /f this condition is not corrected ;uic ly, the client%s heart stops beating and asystole is seen on the +0=. The client ;uic ly becomes faint, loses consciousness, and becomes pulseless. 'ypotension, or a lac of blood pressure, and abnormal heart sounds are present. $igure ).: shows a diagram of the chaotic rhythms typical with &,fib.

FIGURE 3./ &entricular fibrillation diagram. Treatment of ventricular fibrillation is done with a defibrillator set at appro"imately *33 joules. Three ;uic , successive shoc s are delivered, with the third at )93 joules. /f a defibrillator is not readily available, a precordial thump can be delivered. /f cardiac arrest occurs, the nurse should initiate cardiopulmonary resuscitation (0(.) and be ready to administer first,line drugs such as epinephrine or vasopressin ((itressin).

Internal 0acema!er1Internal Cardiac Defi.rillators

An internally implanted pacema er and cardioverter7defibrillator are used to treat ventricular fibrillation, heart bloc , and other dysrhythmias. These devices are usually implanted on the client%s left side and are connected to the myocardium with electrical leads. /f the client e"periences fibrillation or ventricular tachycardia, the defibrillator delivers a shoc to the heart and corrects the pattern. The internal defibrillator also records dysrhythmias the client has e"perienced so that the physician is aware of her condition. A client with an internal cardiac defibrillator or permanent pacema er should

be taught to Avoid elevating her left arm above her head for appro"imately two wee s or until the doctor instructs otherwise. Wear a medic alert stating that a pacema er7internal defibrillator is implanted. /dentification will alert the healthcare wor er so that alterations in care can be made. Ta e pulse for one full minute and report the rate to the physician. Avoid applying pressure over the pacema er. (ressure on the defibrillator or pacema er can interfere with the electrical leads. /nform her dentist of the presence of a pacema er because electrical devices are often used in dentistry. Avoid having a magnetic resonance imaging (A./) test. Aagnetic resonance interferes with the electrical impulse of the implant. Avoid close contact with electrical appliances, electrical or gasoline engines, transmitter towers, antitheft devices, metal detectors, and welding e;uipment because they can interfere with conduction. -e careful when using microwaves. Aicrowaves are generally safe for use, but the client should be taught to stand appro"imately five feet away from the device while coo ing. .eport fever, redness, swelling, or soreness at the implantation site. /f beeping tones are heard coming from the internal defibrillator, the client should immediately move away from any electromagnetic source. !he should stand clear from other people because shoc can affect anyone touching the client during defibrillation. .eport di##iness, fainting, wea ness, blac outs, or a rapid pulse rate. The client will most li ely be told not to drive a car for appro"imately three months after the internal defibrillator is inserted to evaluate any dysrhythmias. .eport persistent hiccupping because this can indicate a misfiring of the pacema er7internal defibrillator.

+ote
-ecause a dye is used to identify the correct placement of the leads, the client should be ;uestioned regarding allergies to shell fish or iodine and advised to force fluids after the procedure and report any difficulty voiding. (!ee the section B0ardiac 0atheteri#ationC for detailed instructions.)

Dia2nostics
The e"am reviewer should be nowledgeable of the preparation and care of clients receiving e"ams to diagnose cardiovascular problems. While reviewing these diagnostic e"ams, the e"am reviewer should be alert for information that would be an important part of nursing care for these clients. The pertinent labs and e"ams are as followsD 0ardiac catheteri#ation 0ardiac 0TA 0ardiac profile 0entral venous pressure monitoring 0hest ",ray 0lotting studies 0omplete blood count 1oppler studies 1ye studies for cardiac functions +chocardiogram +lectrophysiologic studies +"ercise Tolerance Test $luoroscopy A./ E"ygen saturation levels !erum cholesterol and triglycerides !erum electrolytes Thallium scans >ltrasonography &ital signs

0harmacolo2ical A2ents Used in the "reatment of Clients 3ith Cardio)ascular Disorders

An integral part of care to clients with cardiovascular disorders is pharmacological intervention. These medications provide an improvement or cure of the clients% cardiac problems. Table ).< lists e"amples of drugs used to treat cardiovascular disorders, but it is not inclusive of all the medications used to treat disorders of the cardiovascular system. (lease refer to your pharmacology te"t for further information.

"A &E 3.% 0harmacolo2ic A2ents Used in the "reatment of Clients 3ith Cardio)ascular Disorders The nursing e"am reviewer needs to focus on the drugs in Table ).<. /ncluded in this table are the most common side and adverse effects and pertinent nursing care.

A((ly 4our 5no3led2e

The nurse reviewing for the licensure e"am must be able to apple nowledge to meet client needs. >tili#ation of information found in this chapter will help the graduate to answer ;uestions found on the +C&E,.

E#am 6uestions
'. A client with hypertension has an order for furosemide. Which lab finding should be reported to the physicianF A. (hosphorus *.? m+;78 . (otassium 6.: m+;78 C. 0alcium 4.< mg7dl D. Aagnesium *.< m+;78 2. A client is admitted with a diagnosis of heart bloc . The nurse is aware that the pacema er of the heart is theD

A. A& node . (ur inje fibers C. !A node D. -undle of 'is 3. A client is being treated with nitroprusside (Nitropress). The nurse is aware that this medicationD A. !hould be protected from light . /s a non5potassium,sparing diuretic C. 0auses vasoconstriction D. 1ecreases circulation to the e"tremities %. A client being treated with lisinopril (Gestril) develops a hac ing cough. The nurse should tell the client toD A. Ta e half the dose to control the problem . Ta e cough medication to control the problem C. !top the medication D. .eport the problem to the doctor 7. An elderly client ta ing digitalis develops constipation. The nurse is aware that constipation in a client ta ing digitalis mightD A. 1evelop an elevated digitalis level . 'ave a decrease in the digitalis levels C. 'ave alterations in sodium levels D. 1evelop tachycardia 8. The client is suspected of having had a myocardium infarction. Which diagnostic finding is most significantF A. 81' . Troponin C. 0reatinine D. A!T -. A client with an internally implanted defibrillator should be taught toD A. Avoid driving a car . Avoid eating food coo ed in a microwave C. .efrain from using a cellular phone D. .eport swelling at the site /. A client is scheduled for a cardiac catheteri#ation. $ollowing the procedure, the nurse shouldD A. Assess for allergy to iodine . 0hec pulses pro"imal to the site C. Assess the urinary output

D. 0hec to ensure that the client has a consent form signed 9. A client with -uerger%s disease complains of pain in the lower e"tremities. The nurse is aware that -uerger%s disease is also calledD A. (heochromocytoma . /ntermittent claudication C. Hawasa i disease D. Thromboangiitis obliterans ':. A client with an abdominal aneurysm fre;uently complains ofD A. A headache . !hortness of breath only during sleep C. 8ower bac pain D. 1ifficulty voiding

Ans3ers to E#am 6uestions

'. Answer - is correct. The client ta ing furosemide is at ris for developing hypo alemia (decreased potassium) because this drug is a non5potassium,sparing diuretic. A potassium level of 6.: is e"tremely low and might result in cardiac dysrhythmias. Answers A, 0, and 1 are incorrect because the levels noted in the ;uestion are within normal levels. 2. Answer 0 is correct. The pacema er of the heart is the !A node. The impulse moves from the !A node to the A& node on to the right and left bundle branches and finally to the (ur inje fibers. This ma es answers A, -, and 1 incorrect. 3. Answer A is correct. Nitroglycerine preparations should be protected from light because light decreases the effectiveness of this category of medication. Answer is incorrect because Nitropress is not a diuretic. Answer 0 is incorrect because Nitropress is a vasodilator, not a vasoconstrictor. Answer 1 is incorrect because nitroglycerine does not decrease circulation to the e"tremities. %. Answer 1 is correct. A hac ing cough is a common side effect and should be reported to the doctor. The client should not be told to half the dose because this can result in an elevated blood pressure, so answer A is incorrect. Answer - is incorrect because ta ing a cough medication will mas the symptom of a possible allergic reaction. Answer 0 is incorrect because, although the client stops ta ing the medication, this answer states that the client can report the finding to the doctor at the time of the scheduled visit. !he should report this finding immediately. 7. Answer A is correct. The client ta ing digitalis should avoid constipation because constipation can lead to digitalis to"icity. Answer - is incorrect because constipation will not lead to a decrease in the digitalis levels. Answer 0 is incorrect because constipation does not result in alterations in the sodium level. Answer 1 is incorrect because digitalis to"icity will result in brachycardia, not tachycardia. 8. Answer - is correct. The best diagnostic tool for confirming that the client has e"perienced a myocardial infarction is the troponin level. Another lab value associated with a myocardial infarction is the 0HA-. Answer A is incorrect because the 81' is also elevated in clients with muscle trauma not associated with an A/.

Answer 0 is incorrect because the creatinine level indicates renal function. Answer 1 is incorrect because the A!T level is elevated with gallbladder and liver disease as well as muscle inflammation. -. Answer 1 is correct. The client with an implantable defibrillator should report redness, pain, and swelling at the site of the implant. Answers A, -, and 0 are incorrect because the client can drive a car, eat food coo ed in a microwave, and use a cellular phone. The client probably will be told to wait three months to drive a car. 'e should put his food in the microwave and step five feet away from the microwave during coo ing. A cellular phone can be used but should be held in the right hand. /. Answer 0 is correct. The dye used in the procedure can cause a decrease in renal function. The client%s renal function should be assessed and changes reported to the doctor immediately. Answer A is incorrect because the client%s allergies should be chec ed prior to the procedure, not after the procedure. The femoral artery is commonly used as the site for a catheteri#ation. Answer - is incorrect because the pulses should be chec ed distal to the site. Answer 1 is incorrect because the permit should be signed prior to the procedure. 9. Answer 1 is correct. The other name for -uerger%s disease is thromboangiitis obliterans. Answer A is incorrect because pheochromocytoma is an adrenal tumor. Answer - is incorrect because intermittent claudication is pain in an e"tremity when wal ing. Answer 0 is incorrect because Hawasa i disease is an acute vasculitis that can result in an aneurysm in the thoracic area. ':. Answer 0 is correct. 0lients with abdominal aortic aneurysms often complain of nausea, lower bac pain, and feeling their heart beat in the abdomen. Answer A is incorrect because a headache is a symptom of a cerebral aneurysm. Answer - is incorrect because, although the client with an abdominal aneurysm might have shortness of breath, this symptom is not particular to during sleep. Answer 1 is incorrect because difficulty voiding is not associated with an abdominal aneurysm.

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SOURCE: http://www.nursereview.org COMPREHENSIVE TEST 1 1. A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following patients medication does not cause urine discoloration? . Su!" s ! #ine $. %evo&op '. Pheno!phth !ein &. (spirin 2. You are responsible for reviewing the nursing units refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerators contents? . Corg r& $. Hu)u!in *in+e'tion, '. Uro-in se &. Epogen *in+e'tion, . A ! year old female has recently been diagnosed with an autoimmune disease. "he has also recently discovered that she is pregnant. #hich of the following is the only immunoglobulin that will provide protection to the fetus in the womb? . Ig( $. Ig. '. IgE &. Ig/ !. A second year nursing student has $ust suffered a needlestick while working with a patient that is positive for AI%". #hich of the following is the most important action that nursing student should take? . I))e&i te!0 see so'i ! wor-er $. St rt proph0! 'ti' (1T tre t)ent '. St rt proph0! 'ti' Pent )i&e tre t)ent &. See- 'ounse!ing &. A thirty five year old male has been an insulin'dependent diabetic for five years and now is unable to urinate. #hich of the following would you most likely suspect? . (theros'!erosis $. .i $eti' nephrop th0 '. (utono)i' neurop th0 &. So) ti' neurop th0 (. You are taking the history of a )! year old girl who has a *+,I- of ).. /he girl reports inability to eat, induced vomiting and severe constipation. #hich of the following would you most likely suspect? . Mu!tip!e s'!erosis $. (nore2i nervos '. 3u!i)i &. S0ste)i' s'!erosis 0. A 2! year old female is admitted to the 12 for confusion. /his patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. #hich of the following would you most likely suspect? . .iverti'u!osis

$. H0per' !' e)i '. H0po' !' e)i &. Irrit $!e $owe! s0n&ro)e .. 2ho gam is most often used to treat3333 mothers that have a 3333 infant. . RH positive4 RH positive $. RH positive4 RH neg tive '. RH neg tive4 RH positive &. RH neg tive4 RH neg tive 4. A new mother has some 5uestions about *678-. #hich of the following statements made by a nurse is not correct regarding 678? . ( /uthrie test ' n 'he'- the ne'ess r0 ! $ v !ues. $. The urine h s high 'on'entr tion o" phen0!p0ruvi' 'i& '. Ment ! &e"i'its re o"ten present with P5U. &. The e""e'ts o" P5U re reversi$!e. )9. A patient has taken an overdose of aspirin. #hich of the following should a nurse most closely monitor for during acute management of this patient? . Onset o" pu!)on r0 e&e) $. Met $o!i' !- !osis '. Respir tor0 !- !osis &. P r-inson6s &ise se t0pe s0)pto)s )). A fifty'year'old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is? . %et others -now $out the p tient6s &e"i'its $. Co))uni' te with 0our supervisor 0our 'on'erns $out the p tient6s &e"i'its. '. Continuous!0 up& te the p tient on the so'i ! environ)ent. &. Provi&e se'ure environ)ent "or the p tient. )2. A patient is getting discharged from a ":; facility. /he patient has a history of severe <=6% and 6>%. /he patient is primarily concerned about their ability to breath easily. #hich of the following would be the best instruction for this patient? . .eep $re thing te'hni7ues to in're se O8 !eve!s. $. Cough regu! r!0 n& &eep!0 to '!e r irw 0 p ss ges. '. Cough "o!!owing $ron'ho&i! tor uti!i# tion &. .e're se CO8 !eve!s $0 in're se o20gen t -e output &uring )e !s. ) . A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. #hich of the following clinical signs would most likely be present? . S!ow pu!se r te $. 9eight g in '. .e're se& s0sto!i' pressure &. Irregu! r 93C ! $ v !ues )!. A mother has recently been informed that her child has %owns syndrome. You will be assigned to care for the child at shift change. #hich of the following characteristics is not associated with %owns syndrome? . Si)i n 're se $. 3r 'h0'eph !0 '. Oi!0 s-in

&. H0potoni'it0 )&. A patient has recently e?perienced a *,I- within the last ! hours. #hich of the following medications would most like be administered? . Strepto-in se $. (tropine '. ('et )inophen &. Cou) &in )(. A patient asks a nurse, @,y doctor recommended I increase my intake of folic acid. #hat type of foods contain folic acids?A . /reen veget $!es n& !iver $. :e!!ow veget $!es n& re& )e t '. C rrots &. Mi!)0. A nurse is putting together a presentation on meningitis. #hich of the following microorganisms has noted been linked to meningitis in humans? . S. pneu)oni $. H. in"!uen# '. N. )eningitis &. C!. &i""i'i!e )..A nurse is administering blood to a patient who has a low hemoglobin count. /he patient asks how long to 2+<s last in my body? /he correct response is. . The !i"e sp n o" R3C is ;< & 0s. $. The !i"e sp n o" R3C is => & 0s. '. The !i"e sp n o" R3C is ?> & 0s. &. The !i"e sp n o" R3C is 18> & 0s. )4. A (& year old man has been admitted to the hospital for spinal stenosis surgery. #hen does the discharge training and planning begin for this patient? . @o!!owing surger0 $. Upon &)ission '. 9ithin ;A hours o" &is'h rge &. Preoper tive &is'ussion 29. A child is & years old and has been recently admitted into the hospital. According to 1rickson which of the following stages is the child in? . Trust vs. )istrust $. Initi tive vs. gui!t '. (utono)0 vs. sh )e &. Inti) '0 vs. iso! tion 2). A young adult is 29 years old and has been recently admitted into the hospital. According to 1rickson which of the following stages is the adult in? . Trust vs. )istrust $. Initi tive vs. gui!t '. (utono)0 vs. sh )e &. Inti) '0 vs. iso! tion 22. A nurse is making rounds taking vital signs. #hich of the ;

following vital signs is abnormal? . 11 0e r o!& ) !e B ?> $.p.)4 88 resp/)in. 4 1>>/C> )) Hg $. 1D 0e r o!& "e) !e B 1>< $.p.).4 88 resp/)in.4 1></=> )) Hg '. < 0e r o!& ) !eE 1>8 $.p.)4 8; resp/)in.4 ?>/=< )) Hg &. = 0e r o!& "e) !eE 1>> $.p.).4 8= resp/)in.4 ?>/C>)) Hg 2 . #hen you are taking a patients history, she tells you she has been depressed and is dealing with an an?iety disorder. #hich of the following medications would the patient most likely be taking? . E! vi! $. C !'itonin '. Pergo!i&e &. Ver p )i! 2!. #hich of the following conditions would a nurse not administer erythromycin? . C )p0!o$ 'teri ! in"e'tion $. %egionn ire6s &ise se '. Pneu)oni &. Mu!tip!e S'!erosis 5(P%(N :<B1C D81"/I=: /2AI:12 ). /he nurse is supervising care given to a group of patients on the unit. /he nurse observes a staff member entering a patients room wearing gown and gloves. /he nurse knows that the staff member is caring for which of the following patients? 1. (n 1AE)onthEo!& with respir tor0 s0n'0ti ! virus. 8. ( ;E0e rEo!& with 5 w s -i &ise se. D. ( 1>E0e rEo!& with %0)e6s &ise se. ;. ( 1=E0e rEo!& with in"e'tious )ononu'!eosis. 2. /he nurse is assessing a client who has had a spinal cord in$ury. #hich of the following assessment findings would suggest the complication of autonomic dysrefle?ia? 1. Urin r0 $! &&er sp s) p in. 8. Severe poun&ing he & 'he. D. T 'h0' r&i . ;. Severe h0potension. . A )!'year'old client is scheduled for a below'knee *+7- amputation following a motorcycle accident. /he nurse knows preoperative <

teaching for this client should include 1. e2p! ining th t the '!ient wi!! $e w !-ing with prosthesis soon "ter surger0. 8. en'our ging the '!ient to sh re his "ee!ings n& "e rs $out the surger0. D. t -ing the in"or)e& 'onsent "or) to the '!ient n& s-ing hi) to sign it. ;. ev !u ting how the '!ient p! ns to ) int in his s'hoo!wor- &uring hospit !i# tion. !. A 2)'year'old woman at )('weeks gestation undergoes an

amniocentesis. /he client asks the nurse what the physician will learn from this procedure. /he nurses response should be based on an understanding that which of the following conditions can be detected by this test? 1. Tetr !og0 o" @ !!ot. 8. T !ipes e7uinov rus. D. He)o!0ti' &ise se o" the new$orn. ;. C!e"t !ip n& p ! te. &. /he nurse evaluates the nutritional intake of a )('year'old girl at a camp for adolescents. /he girl eats all of the food provided to her at the camp cafeteria. 1ach of the days three meals contains foods from all areas of the food pyramid, and each meal averages about 499 calories and mg of iron. /he girl has been menstruating monthly for about two years. #hich of the following descriptions, if made by the nurse, +1"/ describes the girls intake if her weight is appropriate for her height? 1. Her &iet is !ow in ' !ories n& high in iron. 8. Her &iet is !ow in ' !ories n& !ow in iron. D. Her &iet is high in ' !ories n& !ow in iron. ;. Her &iet is high in ' !ories n& high in iron. (. A client has returned from surgery with a fine, reddened rash noted around the area where +etadine prep had been applied prior to surgery. :ursing documentation in the chart should include 1. the ti)e n& 'ir'u)st n'es un&er whi'h the r sh w s note&. 8. the e2p! n tion given to the '!ient n& " )i!0 o" the re son "or the r sh. D. not tion on n !!erg0 !ist n& noti"i' tion o" the &o'tor. ;. the nee& "or pp!i' tion o" 'orti'osteroi& 're ) to &e're se in"! )) tion. 0. A client who is receiving a blood transfusion e?periences a hemolytic reaction. /he nurse would anticipate which of the following assessment findings? 1. H0potension4 $ '- 'he4 !ow $ '- p in4 "ever. 8. 9et $re th soun&s4 severe shortness o" $re th. D. Chi!!s n& "ever o''urring $out n hour "ter the in"usion st rte&. ;. Urti' ri 4 it'hing4 respir tor0 &istress. .. /he nurse is developing a comprehensive care plan for a young woman with an eating disorder. /he nurse refers this client to assertiveness skills classes. /he nurse knows that this is an appropriate intervention because this client may have problems with 1. ggressive $eh viors n& ngr0 "ee!ings. 8. se!"Ei&entit0 n& se!"Eestee). D. "o'using on re !it0. ;. " )i!0 $oun& r0 intrusions

" i!ure =8. "trategyE %etermine how each answer relates to diabetes insipidus. *1, ! te signs o" in're se& intr 'r ni ! pressure or $r in & ) ge *8, 'orre'tBsigns o" &eh0&r tion4 in're se& output4 !ow spe'i"i' gr vit04 nor) ! 1.>1>E1.>D> *D, signs o" h0perg!0'e)i &ue to &i $etes )e!!itus *;, s0)pto)s o" SI(.H *s0n&ro)e o" in ppropri te nti&iureti' hor)one, re opposite o" &i $etes insipi&us =D. "trategyE /hink about each answer. *1, 'orre'tB)e&i' tion is 'ontr in&i' te& "or the tre t)ent o" !'oho! with&r w ! s0)pto)sF )e&i' tion wi!! !ower '!ientGs sei#ure thresho!& n&

3P4 ' using potenti !!0 serious )e&i' ! 'onse7uen'es *8, not $est r tion !e "or 'he'-ing with &o'tor $out this or&er *D, not $est r tion !e "or 'he'-ing with &o'tor $out this or&er *;, not $est r tion !e "or 'he'-ing with &o'tor $out this or&er =;. "trategyE %etermine the skill level involved with each patientFs care. /he 2: cares for patients that re5uire assessment, teaching, and nursing $udgment. *1, st $!e p tient with n e2pe'te& out'o)e: ssign to the %PN/%VN *8, st $!e p tient with n e2pe'te& out'o)e: ssign to the %PN/%VN *D, st n& r&4 un'h nging pro'e&ure: ssign to the nursing ssist nt *;, 'orre'tBre7uires ssess)ent s-i!!s o" the RN =<. "trategyE /hink about each answer. *1, not in nee& o" restr ints *8, not in nee& o" restr ints *D, 'orre'tB r) restr ints re ne'ess r0 to prevent in" nt "ro) ru$$ing or otherwise &istur$ing suture !ine *;, not in nee& o" restr ints ==. "trategyE %etermine how each answer relates to an intestinal obstruction. *1, 'orre'tBthere is &istention $ove the !eve! o" o$stru'tion n& initi !!0 D<

h0per 'tive $owe! soun&sF wou!& $e no stoo!4 s )oti!it0 &ist ! to *$e!ow, the o$stru'tion wou!& 'e se *8, wou!& $e no &i rrhe *D, wou!& $e no re't ! $!ee&ing4 $&o)en wou!& $e &isten&e& *;, wou!& $e no /I $!ee&ing =C. "trategyE /hink about each answer. *1, wi!! not 'h nge without N r' n4 respir tions in're se within 8 )in *8, .NR in&i' tes no resus'it tion shou!& $e &one i" he rt stopsF &oes not pre'!u&e &)inistr tion o" &rugs to 'orre't i trogeni' pro$!e)s *D, 'orre'tBh !"E!i"e o" N r' n is shortF ) 0 go $ '- into respir tor0 &epressionF ) 0 nee& to $e repe te& *;, use& "or respir tor0 &epression o" opi tes4 not use& with $ r$itur tes or se& tives =A. "trategyE /hink about each answer. *1, &oes not 'ontri$ute to support o" the !u)$ r spine *8, 'orre'tBstrengthening the $&o)in ! )us'!es &&s support "or the )us'!es supporting the !u)$ r spine *D, &oes not 'ontri$ute to support o" the !u)$ r spine *;, &oes not 'ontri$ute to support o" the !u)$ r spine =?. "trategyE /hink about each answer. *1, 'orre'tB'ontr in&i' te&F en'our ges p tient to eng ge in "urther

&istortion o" re !it0 *8, nee&s re !it0 testing "ro) nurse4 not 7uestioning *D, 7uestioning is nonther peuti'F ) 0 ' use p tient to voi& nurse ph0si' !!0 *;, nee&s &e"enseF 7uestioning wi!! "urther &istort re !it0 or e! $or te on &e!usion C>. "trategyE /hink about each answer. *1, +ust the opposite is trueF !ongEter) )e)or0 is )ore e""i'ient th n shortE ter) )e)or0 *8, 'orre'tBstress o" n un" )i!i r situ tion or environ)ent ) 0 !e & to 'on"usion in e!&er!0 '!ients *D, )ent ! st tus n& !e rning $i!it0 re not ""e'te& $0 ging4 !though D=

e!&er!0 '!ient ) 0 $e s!ower t &oing things *;, )ent ! st tus n& !e rning $i!it0 re not ""e'te& $0 ging4 !though e!&er!0 '!ient ) 0 $e s!ower t &oing things C1. "trategyE /hink about each answer. *1, 3P in're ses n& '!ient g ins weight *8, 'orre'tB'!ients with CushingGs s0n&ro)e ten& to !ose weight in their !egs n& h ve pete'hi e n& $ruising *D, no 'orre! tion with urin r0 outputF pot ssiu) in're ses *;, no 'orre! tion with CushingGs s0n&ro)e C8. "trategyE /hink about each answer. *1, re 'tions ' use& $0 preserv tives in insu!in4 whi'h is s )e "or !! t0pes o" insu!in *8, no 'h nge in in'i&en'e o" h0pog!0'e)i or h0perg!0'e)i *D, 'o)p!i' tions re ' use& $0 $!oo& vesse! & ) ge "ro) sug r n& " t &eposits4 not t0pe o" insu!in use& *;, 'orre'tBprotein )o!e'u!es re i&enti' ! with hu) n insu!in CD. "trategyE /hink about each answer and how it relates to AI%"' related dementia. *1, not re!ev nt to this 'on&ition *8, not re!ev nt to this 'on&ition *D, 'orre'tB ppro2i) te!0 =<H o" (I.S '!ients &e)onstr te progressive &e)enti st ge& ''or&ing to severit0 o" &e$i!it tionF ! te st ge is t0pi"ie& $0 'ognitive 'on"usion n& &isorient tion *;, is sign o" e r!0 onset &e)enti C;. "trategyE /hink about each answer. *1, 'orre'tB) +or si&e e""e'ts o" h !operi&o! *H !&o!, in'!u&e he) to!ogi' pro$!e)s4 pri) ri!0 $!oo& &0s'r si n& e2tr p0r )i& ! s0)pto)s *EPS, *8, not seen with h !operi&o! *D, not seen with h !operi&o! *;, not seen with h !operi&o!

DC