ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 34 Questions
Question 1 of 5
The nurse is assessing a patient who has just arrived in the emergency department and notes a pulse deficit. Which of the following actions should the nurse anticipate for the patient?
Correct Answer: D
Rationale: Pulse deficit is a difference between simultaneously obtained apical and radial pulses and indicates that there may be a cardiac dysrhythmia that would be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and echocardiograms are used for diagnosis of other cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit.
Question 2 of 5
The nurse is assessing the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. Which of the following laboratory results is most important for the nurse to review?
Correct Answer: B
Rationale: Cardiac troponins start to elevate hours (average 4-6 hours) after myocardial injury and are specific to myocardium. Creatine kinase-MB (CK-M
B) is specific to myocardial injury and infarction, but it does not increase until 6 hours after the infarction occurs. LDL cholesterol and C-reactive protein are useful in assessing cardiovascular risk but are not helpful in determining whether a patient is having an acute myocardial infarction.
Question 3 of 5
The nurse is assessing an underweight older-adult patient and observes pulsation of the abdominal aorta in the epigastric area. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals and the nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.
Question 4 of 5
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of the following actions included in the standard TEE orders should the nurse accomplish first?
Correct Answer: C
Rationale: The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure.
Question 5 of 5
The nurse is reviewing the 12-lead electrocardiogram (ECG) of a healthy older-adult patient who is having an annual physical examination. Which of the following findings should be of most concern to the nurse?
Correct Answer: A
Rationale: The resting supine HR is not markedly affected with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, the bundle of His, and the bundle branches.