Cardiac/Vascular Nurse Exam Secrets Study Guide (45 page)

105. D. The patient’s verbal and non-verbal responses are of equal importance. Patients may look away or become tense if they are not telling the truth or do not want to answer a question. Information elicited during an interview should include not only facts but also attitudes and concerns. Nurses should ask open-ended questions to elicit information and to clarify information rather than questions answered simply by yes or no. Providing a list of options and rephrasing a patient’s statement may encourage the patient to provide more information.

106. A. The patient on an 800-calorie diet should increase her caloric intake and exercise to maintain weight loss at 1–2 pounds a week. An 800 calorie/ diet is not adequate, and weight lost this quickly usually returns just as soon as the patient increases intake. The patient should increase exercise to 30 minutes/day, and exercise should be maintained for at least 10 minutes at any one session. Patients with diabetes should work with a nutritionist to determine the best diet for their needs rather than just reducing calories.

107. D. Many hearing-impaired patients use some degree of lip-reading, so the nurse should not chew, smoke, or eat while speaking to the patient. The nurse should face the patient at a distance of 2–6 feet, use a normal tone of voice and short sentences, and provide assistive devices as necessary, including writing materials and TDD. phone/relay service. If patients are deaf and know sign language, interpreters should be used for important communication, and the nurse should face the patient during communication, not the interpreter.

108. C. While clinical symptoms, blood tests, and electrocardiogram monitoring are all important, biopsy remains the primary tool to diagnose acute rejection after cardiac transplantation. Acute rejection can occur with few clinical symptoms even when using cyclosporine or tacrolimus to prevent rejection, so routine biopsies are done for the first 3 months after surgery. The first biopsy is generally done in 2 weeks and then once weekly for the first month; biopsies are then tapered to every other week and then once monthly after the initial 3-month period and then every 4–12 months, depending on the institutional protocol.

109. A. The nurse should attend to the spiritual needs of the patient by calling a priest even though the hour is not convenient. A Protestant chaplain cannot perform specific rituals that are important to Catholics, and the patient may not survive or be able to receive communion if the call is delayed. Catholic rituals include:

· Sacrament of Anointing of the Sick: This replaces the last rites (Extreme Unction) and is a bedside blessing.

· Viaticum: This is the “last” Holy Communion and is called the “food for the journey.”

110. D. The apex beat (pulsation) can be observed in about half of patients at about the fifth intercostal space along the left mid-clavicular line. The pulsation is caused by thrusting of the left ventricle. The pulsation is easy to observe in patients with thin chest walls. If the heart is enlarged, the pulsation may be observed at the second intercostal space. Aiming a flashlight at a tangential angle across the chest can help cast a shadow that facilitates observation. If no pulsation is evident, the apex beat can be palpated in the same area.

111. B. Thiazide diuretics are the first-line drugs used to treat stage I hypertension. Stage II hypertension is usually treated with a two-drug combination of a thiazide diuretic with an angiotensin-converting enzyme (ACE) inhibitor, ARB, beta-blocker, or calcium-channel blocker. If there are compelling indications, such as heart failure, post–myocardial infarction, coronary disease risk, diabetes, or chronic kidney disease, then a wide range of drugs may be needed, including diuretics, beta-blockers, ACE inhibitors, ARB, calcium channel blockers, or aldosterone antagonists, depending on the condition.

112. D. The use of medical abbreviations is one of the leading causes of medication errors. While institutions usually have an approved list of abbreviations, sometimes these lists are extensive. In many cases abbreviations and symptoms should be avoided altogether or restricted to a limited list. Illegible handwriting also leads to errors, so orders should be block-printed or written on the computer. Institutions should establish protocols for medication administration, such as double identification of each patient, and should provide lists of similarly named medications.

113. B. Pneumococcal polysaccharide-23 (single dose), influenza (annual), and herpes zoster (single dose) immunizations are recommended for all adults 60–65 years of age and older. Hepatitis B is recommended for older adults with end-stage renal disease (including those receiving dialysis), chronic liver disease, or HIV/AIDS and those in correctional facilities or substance abuse facilities. Hepatitis A is recommended for those at risk because of lifestyle (e.g., men who have sex with men, substance abusers) or medical conditions (e.g., liver disease). International travelers may receive hepatitis A and B vaccines, depending on the destination. There is no hepatitis C vaccine.

114. C. Outcome data provide effective guides for performance improvement activities because they provide evidence of how well a process succeeds though not necessarily the reason. Therefore, outcome data must be evaluated accordingly. It can be difficult to apply sufficient risk stratification to provide validity to outcome data, and it is difficult to attribute the data to any one step in a process. Recidivism rates are one type of outcome data but are not applicable to all situations. Patient satisfaction surveys and staff surveys do not necessarily provide adequate feedback for processes.

115. D. Synthroid 0.88 mg PO daily at 0700 is the correct medication order because of the following: (1) the medication is spelled out; (2) the decimal has a leading zero; (3) PO is clearly written; and (4) “daily” is used instead of “qd,” which can be misinterpreted as qid if the nurse uses periods or does not write clearly. Additionally, a 24-hour time designation is used. “Maalox 30 cc” should be “Maalox 30 mL” because “cc” may be misread as “U” for unit. Instead of “qhs,” which can be misread as “qhr,” “nightly” should be used. “Lasix 40.0 mg” should be “Lasix 40 mg” because the trailing zero may cause someone to read the order as “400 mg.” “MS” could be misread as magnesium sulfate.

116. A. Threatening to force a patient to undergo a treatment is a form of coercion. Nurses can easily intimidate patients into having procedures or treatments they do not want. Regardless of age, patients have the right to choose and refuse treatment. Forcing patients to do something against their will can be considered as borderline abuse. Furthermore, this can sometimes degenerate into actual abuse if physical coercion is involved. If patients are cognitively impaired, other family members may be designated to make decisions, but every effort should be made to gain the patient’s cooperation.

117. D. Sexual dysfunction, including impotence, is quite common after heart transplant surgery and most often relates to antihypertensive drugs. Hypertension is a chronic problem after a heart transplant, especially with some immunosuppressive drugs, such as cyclosporine, and patients may require two or more drugs to control blood pressure. The patient should be given assistance or counseling to deal with sexual dysfunction, both before and after surgery. In some cases, alternative drugs may be used.

118. B. Sinus tachycardia is characterized by a pulse of 100 bpm and above. The rapid pulse decreases diastolic filling time and reduces cardiac output with resultant hypotension and pulmonary edema. Bradycardia is characterized by a pulse of 60 bpm and less. Sinus arrhythmia is characterized by cyclic changes in pulse during respiration and is common in children and young adults; however, it may also occur with vagal stimulation from suctioning, vomiting, or defecating. Premature atrial contractions are essentially extra beats caused by an electrical impulse to the atrium before the sinus node impulse, resulting in an irregular pulse.

119. C. There are different types of outcome data that focus on different measures:

· Integrative data measure mortality, longevity, and cost-effectiveness.

· Clinical data measure symptoms, diagnoses, and staging of disease.

· Physiological data measure physical abnormalities, loss of function, and activities of daily living.

· Psychosocial data measure feelings, perceptions, beliefs, functional impairment, and role performance.

· Perception data measure customer perceptions, evaluations, and satisfactions.

· Organization-wide clinical data measure readmissions, adverse reactions, and deaths.

120. A. Striving for patient satisfaction is a long-term outcome. Process is important, but both short-term and long-term outcome measures should be established. Short-term outcomes show results directly related to process and allow modification of the process, but long-term outcomes (e.g., patient satisfaction) often relate to the general quality of care and may be used retrospectively to evaluate the process or plan for future care. Three types of outcome measures should be identified: clinical, patient functioning, and patient satisfaction.

121. B. Caffeinated beverages (e.g., tea, coffee, hot chocolate) may increase the effects of warfarin (Coumadin). Alcohol intake should be limited to no more than three drinks daily. A daily multivitamin should not affect warfarin, but some herbal medications can affect clotting time. Milk products should not affect warfarin, but foods that are high in vitamin K (e.g., broccoli; green leafy vegetables, such as kale, turnip greens, beet greens; cauliflower; legumes; soybean oil; canola oil) may affect the medication and should be limited.

122. D. While all of these are possible, grief and loss are the most common even if patients are experiencing relief to some degree. Change is very disorienting for the elderly, who must cope with a new environment and new people as well as grief at the loss over former associations and personal belongings. If at all possible, patients should visit the facility before the move, and patients should take some personal belongings, such as family pictures, books, and a few items of clothing.

123. A. The translator should have training in medical vocabulary for both languages so that he or she can adequately translate specialized vocabulary. It is not necessary for the translator to know the patient’s history as the translator’s job is only to translate what is said, not to add information or interpret it. While on-site translators are ideal, translation can also be done on a speakerphone.

124. B. The patient is experiencing anger. People grieve individually and may not go through all stages, but most go through at least two stages. Kübler-Ross’s five stages of grief include:

· Denial, which is a refusal to believe, confusion, or stunned, detached.

· Anger, which can be directed inward (self-blame) or outward.

· Bargaining, or “if–then” thinking (e.g., If I go to church, then I will get better.)

· Depression, which is exhibited as sadness and withdrawal.

· Acceptance or resolution.

125. C. Cardiopulmonary bypass can result in hypotension from third spacing in which extracellular and intracellular fluid accumulates, causing hypovolemia as less fluid is available for circulation. Hypothermia can increase systemic vascular resistance and diuresis, resulting in hypertension. Arrhythmias can occur, resulting in electrolyte imbalances, such as hypokalemia. Hemolysis can occur as the result of pulmonary changes related to the deflation of the lungs, altered blood flow, altered capillary permeability, and reduced colloid osmotic pressure.

126. B. A stress management technique that involves therapeutic imagery is visualization in which the person creates a visual image of the desired outcome, engaging as many senses as possible. Meditation involves freeing the mind of thoughts by focusing on repetitions of words or sounds. Reframing is a method of looking at situations from a different perspective to find positive factors rather than just negative. Venting is expressing feelings, through talking, writing, or artistic expression.

127. D. Physiological changes, the presence or absence of complications, and the extent to which treatment objectives are attained can be considered nurse outcomes. Quality outcomes are generally obtained from the patient, the nurse, and the system. Patient outcomes are functional or behavioral change, trust, ratings, satisfaction, comfort, and quality of life. Nurse outcomes are physiological changes, the presence or absence of complications, and the extent to which treatment objectives are obtained. System outcomes include recidivism, costs, and resource utilization.

128. C. The nurse should arrange for a translator. Children should never be used as translators as they lack vocabulary and understanding about health matters and may not interpret correctly. Other adult family members, such as the wife, should not be asked to answer questions for the patient unless the patient is unable to answer questions because of the health condition, because the wife may not understand medical terms and may not translate correctly. Additionally, the patient may have kept significant information from the family.

129. B. The best response is that a better strategy is to improve her diet and increase exercise. While there is evidence that a moderate intake of wine may slightly increase high-density lipoprotein (HDL), this positive effect does not outweigh the negative outcomes of alcohol. The American Heart Association (AHA) does not at this time recommend that anyone drink alcohol to improve heart health or cholesterol levels. If people already drink, the AHA recommends that women limit alcohol to one drink daily and men to two. One drink equals 12 ounces of beer, 4 ounces of wine, or 1 ounce of 100-proof spirits.