QUESTION ANSWERS RATIONALE Which laboratory value will be most important for the nurse to monitor to determine whether a client with chest pain has acute coronary syndrome (ACS)? TROPONIN T (CTNT) C-REACTIVE PROTEIN LOW-DENSITY LIPOPROTEIN B-TYPE NATRIURETIC PROTEIN Cardiac troponins are released into circulation within hours after myocardial injury or infarction, and elevation in troponin levels helps determine that the client is experiencing ACS. The other three values will also be monitored but are not markers for ACS or acute myocardial infarction. C-reactive protein is a marker for inflammation and elevated levels can predict cardiac disease. Elevated LDL is a risk factor for atherosclerosis and coronary artery disease. Elevated BNP is diagnostic for heart failure. THE MEASURED HEMOGLOBIN LEVEL OF A 30 YR OLD FEMALE CLIENT WAS 8MG/DL (80G/L). WHICH INTEGUMENTARY FINDINGS WOUL PALLOR Hemoglobin levels less than 12 mg/dL (120 g/L) in a female result in anemia. Integu BRITTLE NAILS * KOILONYCHIA * CLUBBING CARE AU LAIT SPOTS MENTARY FINDINGS WOULD THE NURSE IDENTIFY IN THIS CLIENT? SELECT ALL THAT APPLY. ale result in anemia. Integumentary manifestations of anemia include pallor, brittle nails, concave nails (koilonychias), and intolerance to cold temperatures. Club ce to cold temperatures. Clubbing is an integumentary manifestation of heart and lung diseases from chronic hypoxia. Café au lait spots are tan-brown patches tha pots are tan-brown patches that are usually nonpathogenic. Creatine 0.8-1.3 mg/dL Potassium 3.7-5.2 mEq/L Hemoglobin 12.0-16.0 g/dL 13.5-17.5 g/dL Women Men QUESTIONS Which patient with type 1 diabetes would be at the highest risk for developing hypoglycemic unawareness? The nurse is reviewing laboratory results for a patient with a 15- year history of type 2 diabetes. Which result reflects the expected pattern accompany macrovascular disease as a ccomplication of diabetes The newly diagnosed pt with type 2 diabetes has been prescribed metformin. What should the nurse teach the patient to explain how this medication works? A patient is admitted with diabetes, malnutrition, cellulitis, and potassium level of 5.6mEq?L. The nurse understands that what could be conributing factors for this lab results ( SELCT ALL THAT APPLY) A patient w/ type 2 diabetes has a UTI, is difficult to arouse, and has a blood glucose of 642 mgdL. When the nurse assesses the urne, thre are no ketones presnet. What nursing action is appropriate a this time? The patient received regular insulin 10 units subcut at 830pm for bg of 253 mg/dL. The nurs eplans to monitor this patient for signs of hypoglycemia at which time related t othe insulins peak action? A patient with diabetes who has mulitiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nure should provide to prevent a cardiac infection postoperatively? The nurse teaches a pt with diabetes about a healthy eating plan. Which statement by the pt indicates that teaching was successful? The nurse is reviewing laborator results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes? A pt, admitted with diabetes, has a glucose level of 580 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? The nurse instructs a client with Type 2 diabetes on which of the adverse interactions between metformin and cimetidine? A nurse is providing instruction with client demonstration on self -administration of insulin. Which of the following TEACH BACK actions will th nurse observe by te client? SELECT ALL THAT APPPLY? A client in the hospital voices concern that the blood glucose monitor may not be working because the blood glucose was 295. After reviewing the medications, the nurse explains which of the following would cause elevated blood glucose? The nurse is discussing complications of diabetes with a client. Which condition is the most common microvascular complication associated with diabetes? The nurse is alerted that dietary trays are going to be late to client rooms and will arrive at 0800 instead of 0730. The nurse plans to administer insulin aspart at 0800. What time should the nurse provide the morning meal? The nurse is providing instruction to a client on selfadministration of lispro (Humalog) insulin. The nurse will stress which time frames to administer the injection of lispro insulin? The nurse is providing diabetic education on Type I diabetes to a newly diagnosed 13-year-old. Which non-pharmacological instruction will most benefit health promotion while living with Type I diabetes? A 28 yo male pt with type 1 diabetes reports how he manages his exercise and glucose control Which behavior indictes that the nurse should implement additional teaching? A pt with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectivesnns of treatment for the patient? A 55 yo female pt with type 2 diabetes has a nursing dx of imbalanced nutrition, more than body requirments. Which goal is most important for this pt? A 38 yo pt has type 1 diabetes plans to swim laps daily at 1pm. The clinic nurse will plan to teach the pt to Increase the morning dose of neutral protamine hagedorn insulin (NPH) time the morning insulin injection so that the peack occurs while swimming DIABETES ANSWERS OPTIONS 58 yo pt with diabetic retinopathy 73 yr old who take propranolol 19 yo who is on school track team 24 yo with a hemoglobin AiC of 8.9% Increased triglyceride levels Increased high-density liporoteins (HDL) Decreased low-density lipoprotiens (LDL) Decreased very-low-density lipoproteins (VLDL) Increases insulin production from the pancreas Slows the absorption of carbohydrate in the small intestine Reduces glucose prodcution by the liver and enhances insulin sensitivity Increases insulin release from the pancreas and inhibits flucagon secreion This patient may be exreting sodium and retaining potassium from malnutrition The level is consistent with renal insufficency from renal nephropathy The levels may be high b/c of dehydration that accompanies hyperglycemia The level may be raided due to metabolic ketoacidosis caused by hyperglycemia This level shows adequate treatment of the cellulitis and acceptable glucose control Routine insulin therapy and exercise Adminiser a different antibiotic for the UTI Administer IV fluids rapidly to correct dehydration Cardiac monitoring to detect potassium changes 840pm to 900pm 900pm to 1130pm 1030pm to 130am 1230am to 830 am Avoid sick people and wash hands Obtain comprehensive dental care Maintain hemoglobin A1C below 7% Coughing and deep brething with splinting I plan to lose 25 lbs this year by following a high protein diet I may have a hypoglycemic reaction if I drink alcohol on an empty stomach I should include more fiber in my diet than a person who does not have diabetes If I use an insulin pump, I will not need to liit foods with saturated fat in my diet a 48 yr old woman with a hemoglobin A1C of 8.4% A 58 yr old man with a fasting blood glucose of 111 mg/dL A 68 yr old woman with a random plasma glucose of 190 mg/dL A 78 yr old man with a 2 hour glucose tolerance plasma glucose of 184mg/dL Central Apnea Hypoventilation Kussmaul respirations Cheyne-Stokes Respirations Taking metformin with cimetidine will result in an increase in metformin levels and risk of hypoglycemia Patient takes a vial and gently rotates it and states, “I will ensure that the insulin vial is never shaken.” Patient describes where insulin will be stored, then states, “ I will never freeze insulin.” Patient performs mock injection site selection and states, “I will rotate sites.” Patient states, “On days I am sick and cannot eat or am vomiting, I will skip my insulin so my blood sugar will not get too low.” Quinidine Prednisone Atenolol Sulfamethoxazole-trimethoprim Myocardial Infarction Ketoacidosis Metabolic Syndrome Diabetic retinopathy 750 805 830 840 Inject lispro subcutaneous daily at noon Inject lispro subcutaneous nightly prior to bedtime snack Inject lispro subcutaneous 30 minutes prior to breakfast Inject lispro subcutaneous 15 minutes prior to eating Perform routine physical exercise Do not take insulin while ill 50% of daily intake should be from protien Oral hypglycemic medications may be given in between insulin The pt always carries hard candies when engaging in exercise the pt goes for vigorous walks when glucose is 200 the pt has bp sandwich before going for a bicycle ride the pt increaes daily exercise when ketones are presnet in the urine Urine dipstick for glucose Oral glucose tolerance test Fasting blood glucose level Glycosylated hemoglobin level (A1C/HBA1c) The pt will reach a glycosylated hemoglobin level of less than 7% The pt will follow a diet and exercise plan that results in weight loss The pt will choose a diet that distritbues calories throughout the day The patient will state the reasons for eliminating simple sugars in the diet Check glucose level before, during, and after swimming delay eating the noon meal until after the swimming class Increase the morning dose of neutral protamine hagedorn insulin (NPH) time the morning insulin injection so that the peack occurs while swimming RATIONALE Hypoglycemic unawareness is a condition in which a person does not have the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or loses consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Older patients and patients who use β-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness. Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development. Metformin is a biguanide that reduces glucose production by the liver and enhances the tissue’s insulin sensitivity. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-Glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying. The additional stress of cellulitis may lead to an increase in the patient’s serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. The kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis because potassium will leave the cell when hydrogen enters in an attempt to compensate for a low pH. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus, it is not a contributing factor to this patient’s potassium level. The increased potassium level does not show adequate treatment of cellulitis or acceptable glucose control. This patient has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough, and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise, requiring hemodynamic monitoring to avoid fluid overload during fluid replacement. Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin’s onset is between 10 and 30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM. A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1C below 7%, and coughing and deep breathing with splinting would be important for any type of surgery but are not the priority for this patient with mitral valve replacement. Eating carbohydrates when drinking alcohol reduces the risk for alcohol-induced hypoglycemia. Intensified insulin therapy, such as the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for alterations from usual eating and exercise habits. However, saturated fat intake should still be limited to less than 7% of total daily calories. Daily fiber intake of 14 g/1000 kcal is recommended for the general population and for patients with diabetes. High-protein diets are not recommended for weight loss Criteria for a diagnosis of diabetes include a hemoglobin A1C of 6.5% or greater, fasting plasma glucose level of 126 mg/dL or greater, 2-hour plasma glucose level of 200 mg/dL or greater during an oral glucose tolerance test, or classic symptoms of hyperglycemia or hyperglycemic crisis with a random plasma glucose of 200 mg/dL or greater. In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis. This answer is correct because if given with the over-the-counter H2 antagonist, cimetidine, blood levels of metformin can increase, causing a risk of hypoglycemia. Clients should be taught to avoid combining these two medications due to this risk. Other over-the-counter medications for gastroesophageal reflux disease, such as proton pump inhibitors, could be considered since those medications are effective against the gastrointestinal symptoms associated with metformin. This answer is correct because the client should understand and demonstrate the importance of gently rotating the vial of insulin before administration (not shake). Shaking can cause bubbles and may interfere with the absorption of the medication. Rolling the vial in the hands is also a good way to mix insulin suspensions. This answer is correct because the client should understand and demonstrate the importance of never freezing insulin. Insulin should be kept away from heat and light. Insulin that is not currently being used and needing storage, should be kept in the refrigerator between 36-46 degrees F until needed. Insulin being currently used should be used at room temperature (between 56-80 degrees F) and should be kept at room temperature for no more than 30 days This answer is correct because the client should understand and demonstrate the importance of how to inject insulin, including the importance of rotating sites. Rotating sites is important since it will be safer, easier, and less uncomfortable. If repeated site usage occurs, the client may develop areas that are hardened (lipohypertrophy) that will keep the insulin from absorbing properly. This answer is not correct because infection usually increases the body’s need for insulin. The hormones that are released to fight infection make it more difficult for the body to use insulin. The client is to continue to take insulin as prescribed and call the health care provider (HCP) for specific instructions if there is a concern. a common side effect of prednisone is increased blood glucose, especially in the diabetic client. Close monitoring of blood glucose is important for the diabetic client with additional needs for insulin or other glucose lowering medications or activity to help maintain normal blood glucose levels. most common microvascular complication associated with diabetes and must be monitored closely. Diabetic retinopathy is a complication of uncontrolled blood glucose levels in the diabetic. Diabetic retinopathy is damage that occurs to the microvascular vessels within the retina. The retina is the light-sensitive tissue of the back of the eye. In the beginning, there may be no to little symptoms of diabetic retinopathy, but later blindness can occur. A dilated fundus examination every 6 months by an eye health care provider (HCP) is strongly encouraged for all diabetics to watch for changes in the retina. Insulin aspart is an insulin with onset of action of 5 to 15 minutes. If a client is receiving insulin aspart, the meal should be given within 5 minutes so the client will not experience hypoglycemia. Essentially, the meal should be sitting in front of the client when the nurse administers the insulin aspart to assure availability of food. Otherwise, the nurse should provide a snack if the meal is delayed to make sure the client does not experience hypoglycemia lispro is a fast-acting insulin that starts to work 15 minutes after being given. The insulin peaks in about an hour and continues to work for 2 to 4 hours. The client taking lispro should eat within 15 minutes of receiving lispro, otherwise, there is a risk of hypoglycemia. exercise is the most beneficial non-pharmacologic habit a teen can participate in. Only insulin and physical exercise will lower the blood glucose for this person. Routine physical exercise is beneficial for diabetics and the teen may need to learn how to take self blood sugars before and after activity and to carry forms of sugar. Exercise benefits those with Type I diabetes since it may help increase insulin sensitivity which means the body may not need as much insulin to process carbohydrates. Safely incorporating exercise will help with long-term life styles into adulthood. when the pt is ketotic, exercise may result in an increase in blood glucose level. Type 1 diabetic pt should be taught to avoid exercise when ketosis is presnet. shows overall control of glucose over 90-120 days. A FB level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for montitoringglucose cntorl once diabete has been diagnosed. The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcmes also are appropriate but are not as high in priority. the change in exercise will affect blood glucose, and the pt will need to mnitor glucose carefully to determine the need for changes in diet and insulin administration. BC exercise tends to decrease blood glucose, patiens are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with increaded exercise. Questions Which nursing intervention will be most effective when assisting the patient with coronary artery disease (CAD) to make appropriate dietary changes? Answers Rationale Give the patient a list of low-sodium, low-cholesterol foods that hould be included in the diet Emphasize the increased risk for heart problems unless the patient makes the dietary changes Help the patient modify favorite high-fat recipes by using monosaturated oils when possible Lifestyle changes are more likely to be successful when consideration is given to the patients values and preferences. The highest percentage of calories from fat should come from monosaturated fat. Although low sodium and low cholesterol foods are appproriate, providing h pt with a list alone is NOT likely to be successful in making dietary changes. Completely removing saturated fat from teh diet is not a realistic expectation. Up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful. Inform the pt that a diet containing no staruated fat and minimal salt will be necessary Which statement made by a patient with coronary artery disease after the nurse has completed teaching about therapeutic lifestyle changes (TLC) diet indicatas that futer teaching is needed? I will switch from whole milk to 1% milk I like salmon and I will plan to eat it more often I can have a glass of wine with dinnfer if I want one I will miss being able to eat PB sandwiches Although only 30% of the daily cals should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include pb sandwiches as part of the TLC diet. The other patient comments indicate a good understaning of the TLC diet The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (LOPRESSOR) if the Pt is restless and agitated BP is 90/54 pt complains about feeling anxious cardiac monitorshow a hr of 61 bpm take b-adrenergic blockers should be monitored for hypotension and bradycardia. This class of medication inhibits the sympathetic nervous system, restlesness, agitation, hypertension, and anxity will not be side effects. When titrating IV nitroglycerin for a pt w/ a MI, which action will the nurse atake to evaluate the effectiveness of the medication? Monitor HR Ask about chest pain Check BP Observe for dysrhythmias The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor HR and BP and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective. In preparation for discharge, the nurse teaches a pt with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which pt statement indicates that the teaching has been effective? I will check my pulse rate before I take any nitroglycerin tablets I will put the nitroglycerin patch on as soon as I get any chest pain I will stop what I am doing and sit down before I put the nitroglycerin under my tongue I will be sure to remove the nitroglycerin patch before taking any sublingual nitroglycerin The pt should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hyptensio. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublinqual nitroglycerin. Although the nurse should check bp before giving niroglycerin, patients do not need to check the pulse rate before taking nitrate. A pt with hyperlipidemia has a new order for colesevelam. Which nursing action is most appropriate when giving the medication? Have the pt take this medciation with an aspirin Administer the medication at the patients usual bedtime Have the pt take the colesevelam with a sip of water Give the pt other meds 2 hours after the colesevelam The bile acid sequestrants interfere with the absorption of many other drugs, and giving oher medications at the same time should be avoided. Taking aspirin concurrently w/ the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. An increased fluid intake is encouraged for patients taking the bile acid sequestrants to reduce the risk for constipation. For maximum effect, colesevelam should be administerd with meals. Which assessment finding by the nurse caring for a pt who has had coronary artery bypass grafting using a right radial artery graft is MOST important to communicate to the hcp? Complaints of incisional chest pain Pallor and weaknes of the right hand Finecrackles heard at both lung bases Redness on both sides of the sternal incision The changes in the right hand indicate comproised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions. After receiving change of shift report about the following 4 patients, which patient should the nurse assess first? 39 yo with pericarditis who is complaining of charp, stabbing chest pain 56 yo with variant angina who is to recive a dose of nifedipine 65 yo who had mycardial infarction 4 days ago and is anxious about the planned d/c 59 year old with unstable angina who has just returned to the unti after having a percutaneous This pt is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the pts bp, pulse and the access coronary intervention site immediately. The other pt should also be assessed as quickly as possible, but assessmet of this pt has the highest priority. A pt with diabetes mellitus and chronic stable angina has a new order for captopril. The nurse should teach the pt that the primary purpose of captopril is to lower heart rate control blood glucose levels prevent changes in the heart muscle reduce the frequency of chest ain The purpose for angiotenin-converting enzyme (ACE) inhibitors in pts with chronic stable angina who are at high risk for a cardiac event I to decrease ventricular remodeling. ACE inhibitors do not directly impact angina frequency, blood glucose, or heart rate. After reviewing a pts history , vital signs, physical assessment, and lab data , which info showing is MOST important for the nurse to communicate to the HCP? Q waves on ECG Elevaed troponin levels Fever and hyperglycemia Tachypnea and crackles in lungs Pulmonary congestion and tachypnea suggest that thepatient may be developing heart failure, a complication of MI. Mild fever and hyperglycemia are common after MI b/c of the inflammatory process that occurs with tissue necrosis. Troponin levels will be elevated for several days after MI. Q waves often develop with ST-segment-elevation MI. Hypertension QUESTIONS x ANSWERS OPTIONS RATIONALE The nurse is caring for a patient with HYPERTENSION who is scheduled to receive a dose of metoprolol (Lopressor). The nurse should withhold the dose and consult the prescribing provider for which vital sign take just before administration? 02 saturation 93% Pulse 48 beats/min Respirations 24 breaths/min B/C METOPROLOL IS A B1-ADRENERGIC BLOCKING AGENT, IT CAN CAUSE HYPTO TENSION AND BRADY CARDIA AS ADVERSE EFFECTS. THE NURSE SHOULD WITHOLD THE DOSE AND CONSULT WITH THE HCP FOR PARAMETERS REGARDING PULSE RATE LIMITS Blood pressure 118/74 Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressure over 140/90 mm Hg. What should the nurse do next? Assess his adherence to therapy Ask him to make an exercise plan Teach him to follow the DASH diet A long-acting calcium-channel blocker such as nifedipine causes vascular smooth muslce relaxation, resulting in decreased systemic vascular reistance and arterial blood pressure and related side effects. The patient data the has about this patient is very limited, so the nurse needs to begin by assesing adherance to therapy. Request a prescription for a thiazide diuretic In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? Serum Uric Acid of 3.8 mg/dL Serum creatinine of 2.6 mg/dL Serum potassium of 3.5 mEq/L The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other laboratory results are within normal limits. Blood urea nitrogen of 15mg/dL The UAP is taking orthostatic vital signs. In the supine position, the BP is 130/80mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position , the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UP to take next? Repeat BP and HR in this position Record the BP and HR measurements Take BP and HR with patient standing Return the patient to the supine position The vital signs taken do not reflect orthostatic changes, so the UAP will continue with the measurements while the patient is standing. There is no need to repeat or delay the readings. The patient does NOT need to return to the supine position. When assessing for orthostatic changes, the UAP will take the BP and pulse in the supine position, then place the patient in a sitting position for 1 to 2 minutes and repeat the readings, and then reposition to the standing position for 1 to 2 mins and repeat the readings. Results consistent with orthostatic changes would have a decrease of 20 mm Hg or more in systolic BP, a decrease of 10 mm Hg or more in diatolic BP, and/or an increase in HR of greater than or equal to 20 beats/min with position changes. The nurse is caring for a patient admitted with a history of hypertension. The patients medication history includes hydrochlorothiazide daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? BP 128/78 mm Hg Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medciations if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Because the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the BP. Weight loss of 2 lbs Absence of ankle edema Output of 600 mL per 8 hours When providing dietary teaching to a patient with hypertension, the nurse would teach the patient to restrict intake of which meat? Broiled Fish Roasted Duck Roasted Turkey Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progres of atheroscelerosis and overall cardiovascular disease risk. The other meats are lower in fat and are therfore acceptable in the diet. Roasted Check Breast When teaching how lisinopril (Zestril) will help lower the patient's BP, whch mechanism of action should the nurse explain? Blcoks B-Adrenergic effects Relaxes arterial and veous smooth muscles Inhibits conversion of angiotensin I to angiotensin II Lisinopril is an angiotensin-converting enzyme inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II- medicated vasoconstriction and sodium and water retention. B-Blockers result in vasodilation and decreased HR. Direct vasodilators relax arterial and venous smooth muscle. Central-acting a-adrenergic antagonists reduce sympathetic outflow from the central nervous system to prodcue vasodilation and decreased systemic vascular resistance and BP. Reduces sympathetic outflow from CNS The nurse is caring for a patient admitted with COPD, angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assess the patient carefully. Which adverse effect is this patient at tisk for given the patient's health history? Hypocapnia Tachycardia Bronchospasm Nausea and vomiting Atenolol is a cardioselective B1-adrenergic blocker that reduces BP and could affect the B2-Receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective B-Blockers than nonselective B-Blockers , atenolol should be used cautiously in patients with COPD The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? Hypertension promotes atherosclerosis and damage to the walls of the arteries Hypertension causes direct pressure on organs, resulting in necrosis and scar tissue Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems Hypertension increases blood viscosity, which causes intravascular coagulation and tissue necrosis distal to occlusions. A 44-yr-old man is diagnosed with hypertension and receives a prescripton for benazepril (Lotensin). After providing teaching, which statement by the patient indicates correct understanding? "If I take this medication, I will not need to follow a special diet" " It is normal to have some swelling in my face while taking this medciation" " I will need to eat foods such as bananas and potatoes that are high in potassium: Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, when atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues. Benazepril is an angiotensin-converting enzyme inhibitor. The medciation inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indciate angioedema and should be reported " If I develop a dry cough while taking this medciation, I should immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modicications to lower notify my doctor" blood pressure such as a reduced sodium diet. The nurse is taching a women's group about ways to prevent hypertension. What information should the nurse include? ( SELECT ALL THAT APPLY) Lose Weight Limit beef consumption Limit sodium and fat intake Increase fruits and vegetables Exercise 30 mins most days Primary prevention of hypertension is to make lifestyle modications that prevent or delay the increase in BP Along with exercise for 30 mins on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Beef includes saturated fats, which should be limited. Weight loss may or may not be necessary, depending on the person. The nurse supervises an UAP who is taking the BP of an obese pt admitted with HF. Which action by the UAP will require the nurse to intervene? Deflating the BP cuff at a rate of 8 to 10mm Hg/sec Waiting 2 mins after position changes to take orthostatic pressures Taking the BP with the pt arm at the level of the heart The cuff should be deflated at a rate of 2 to 3 mm Hg/sec. The arm should be supported at the level of the heart for accurate BP measurements. Using a cuff that is too small causes a falsely high reading and too large causes a falsely low reading. If the maximum size BP cuff does NOT fit the upper arm, the forearm may be used. Orthostatic BP should be taken within 1 to 2 mins of repositioning the patient. Take a forearm BP if the largest cuff will not fit the pt upper arm The nurse admits a 73-yr-old male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication? Clonidine( Catapres) Bumetanide (Bumex) Amiloride (Midamor) Spironolactone (Aldactone) Bumetanide is a loop diuretic. Hypokalemia is a common adverse effect of this medication. Amiloride is a potassium-sparing diuretic. Spironolactone is an aldosterone-receptor blocker. Hyperkalemia is an adverse effect of both amiloride and spironolactone. Clonidine is a central-acting a-adrenergic antagonist and does not cause electrolyte abnormalities The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications reduced his BP. Which patient statement requires reinforcement of teaching? "I will avoid adding salt to my food during or after cooking" "If I lose weight, I might not need to continue taking medications" "I can lower my BP by switching to smokeless tobacco" Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction & increase BP. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of foord or at meals. Weight loss can decrease BP between 5 to 20 mm Hg. Following dietary recommendations (DASH DIET) lowers bp, and these decreases compare with those achieved with BP-lowering medication. Diet changes can be as effective as taking BP medciations A patient with a history of chronic hypertension is being evluated in the emergency department for a BP of 200/140 mm Hg. Which patient assessment question is the priority? Is the patient pregnant Does the patient need to urinate Does the patient have a headache or confusion Is the patient taking antiseizure meds as prescribed? The nurse's priority assessments include neurologic deficits, retinal damage, HF, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertnsive encephalopathy from increased cerebral capillary permeability leading to cerbral edema. In addition, headache or confusion could represent signs and symtpoms of a hemorrhagic stroke. Pregnancy can lead to secondary hypertension. Nedding to urinate and taking antisizure medication do not support a hypertensive emergency. When teaching a patient about dietary management of stage 1 hypertension, which instruction is appropriate? Increase water intake Restrict sodium intake The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Protein intake does not affect hypertension. Calcium supplements are not recommended to lower BP. Increase protein intake Use calcium supplements A 67-yr-old woman with hypertension is admitted to the ER Dept. with a BP of 234/148 mm Hg and was started on nitroprusside. After 1 hour of tx, the mean arterial blood pressure (MAP) is 55 mm Hg. Which nursing action is a priority? Start an infusion of 0.9% normal saline at 100mL/hr Maintain the current administration rate of nitroprusside Request insertion of an arterial line for accurate BP monitoring Stop the nitroprusside infusion and assess the pt for potential complications Nitroprusside is a potent vasodilator medciation. A BP of 235/118 mm Hg would have a calculated MAP of 177 mm Hg. Subtracting 25% (44mg)- 133 mm Hg. The initial tx goal is to decrease MAP by NO MORE THAN 25% within minutes to 1 hour. For this PT , the goal MAP would be around 133 mm Hg. Minimal MAP required to perfuse organs is around 60 - 65 mm Hg. Lowering the blood pressure too rapidly may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infaction, or renal failure. The priority is to stop the nitroprusside infusion and then use fluids only if necessary to support restoration of MAP. Systolic BP increases with aging White coat syndrome is prevalent in older patients Volume depletion contributes to orthostatic hypotension *Systolic bp increases w/ age & pt older than age 60 should be maintained below 150/90 mm Hg. * Older adults are more likely to have elevated np when taken by hcp (white coat syndrome) Older pt * have orthostatic hyptension related to dehydration, reduced compensatory mechanisms & meds BP should be maintained near 120/80 mm Hg BP drops 1 hour after eating in many older patients Older patients require higher doses of antihypertensive medciations * One hour after eating, many older pt have a drop in BP. Lower doses of meds may be needed to control BP * in older adults related to decreased absorption rates and excretion ability. Which information should the nurse consider when planning care for older adult patients with hypertensions (SELECT ALL THAT APPLY) The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is MOST important to report to the health care provider? Urine output over 8 hours is 250mL less than the fluid intake The patients inability to move the left arm and leg indicates that a hemorrhagic stroke may be occuriig and wil require immediate action to prevent further neurologic damage. The other clinical manifestations are The patient cannot move the left arm and leg when asked to do also likely caused by the ypertension and will require rapid nursing actions, but they do not require action as so urgently as the neurologic hcanges Tremors are noted in the fingers when the patient extends the arms The patient complains of a headache with pain at level 8/10 (0-10 scale) Which assessment finding for a patient who is reciving IV furosemide (LASIX) to treat stage 2 hypertension is MOST iportant to report to the health care provider? Blood Glucose of 175 Potassium of 3.0 BP 168/94 Orthostatic systolic BP decrease of 12 HEART FAILURE QUESTIONS ANSWERS RATIONALES The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the folliwng gindings: SODIUM 139 mEq/L, POTASSIUM 5.6 mEq/L, CHLORIDE 103mEq/L, and glucose 106mg/dL. What is the priority action by the nurse? Withold the daily dose until the following day Withold the dose and repot the potassium level Give the digoxin with a salty snack, such as crackers Give the digoxin with extra fluids to dilute the sodium level The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and wait for the potassium level to normalize. The provider may order the digoxin to be given once the potassium level has been treated and decreases to within normal range. A patient with a recent diagnosis of heart failure has been prescribed furosemide (LASIX) what outcome would demonstrate medication effectiveness? Promote vvasodilation Reduction of preload Decease in afterload Increase in contractility Diuretics such as furosemide are used in the treatment of heart failure to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone. A patient admitted with heart failure is anxious and reports shortness of breath. Which nursing actions woul dbe appropriate to alleviate the patients anxity? ( SELECT ALL THAT APPLY.) Administer ordered morphine sulfate Postion patient in a semi-fowlers position Morphine sulfate reduces anxiety and may assist in reducing dyspnea. Pt should be in semi-fowler to improve Instruct patient on the use of relaxation techniques ventilation , relaxation techniques and a calm Use a calm, reassuring approach while talking to the patient reassuring approach will also serve to reduce anxiety Position pt on left side with head of bed flat What should the nurse recognize as an indication for the use of dopamine in the care of a patient with heart failure? Acute anxiety Hypotension and tachycardia Peripheral edema and weight gain paroxysmal nocturnal dyspnea Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine. What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (natrecor) to treat hear failure? Urine output Lung sounds Blood Pressure Respiratory rate Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide. The home care nurse visits a patient with chronic heart failure. Which assessment findings would indicate acute decompensated heart failure (pulmonary edema) Fatique, orthopnea, and dependent edema Severe dyspnea and bood-streaked, frothy sputum Manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate greater than 30 breaths/min, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased. Temperature is 100.4 F and pulse is 102 beats/min Respirations 26 breaths/min despite oxygen by nasal cannula The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care fo this patiet? (SELECT ALL THAT APPPLY) Left Ventricular function is documented Education materials about activity, medications, weight monitoring and what to do if symptoms worsen prescription for angiotensin-converting enzyme inhibitor at discharge Controlling dysrhythmias will eliminate HF Prescription for digoxin The Joint Commission has identified these 3 core measures for HF pt. Although controlling dysrhythmias will improve CO and worload, it will nto eliminate HF. Prescribing digoxing for all HF patients is no longer done b/c there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained. A patient is scheduled for a heart transplant. What is a major cause of death beyond the first year after a heart transplant? Infection acute rejection Immunosuppression Cardiac Vasculopathy Beyond the first year after a heart transplant, cancer (especially lymphoma) and cardiac vasculopathy (accelerated coronary artery disease) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient’s risk of an infection. The nurse is administering a dose of Digitalis (digoxin) to a patient with heart failure (HF). The nurse would beecome concerned with the possibility of digitalis toxicity if the patient reported which symtpom? Muscle Aches Constipation Loss of appetite Pounding headache Anorexia, nausea, vomiting, blurred or yellow vision, and dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms. A patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first? Review urinary output for the previous 24 hour Restrict the patients oral fluid intake to 500mL/day Assist the pt to a siting position with arms on the overbed table Teach the pt to use pursed-lip breathing until the dyspnea subsides The nurse should place the patient with ADHF in a high Fowler’s position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect. An older adult pt w/ Chronic HF and atrial fibrillation asks the nurse why warfarin has been prescribed to contue at home. What is the best response by the nurse? Chronic HF causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin The medication prevents blood clots from forming is an anticoagulant that interferes with hepatic synthesis of vitamin K–dependent in your heart clotting factors. The medication dissolves clots that develop in your coronary arteries The medication reduces clotting by decreasing serum potassium levels The medication increases your heart rate so that clots do not form in your heart A patient has been placed on a milrinone infusion as part of the therapy for end-stage heart failure. What adverse effect of this drug will the nurse watch for when assessing this patient during the infusion? Hypertension Hyperkalemia Nausea and vomitting Cardiac dysrhythmias The primary adverse effects seen with the milrione are cardiac dysrhythmias, mainly ventricular. It may also cause hypotension, hypokalemia, and other effects, but not nausea and vomiting. The nurse is reviewing discharge teaching for a patient who will be taking digoxin therapy. The nure will teach the patien tto aovid which foods when taking the digoxin? Leafy green vegetables Dairy products Grapefruit juice Bran muffins Bran, in large amounts, may decrease the absorption of oral digitalis drugs. The other foods do not affect digoxin levels. In assessing a patient before administration of a cardiac glycoside, the nurse knows that which lab result can increse the toxicity of the drug? Potassium level 2.8mEq/L Potassium level 4.9 mEq/L Sodium level 140 mEq/L Calcium level 10mg/dL Hypokalemia increases the chance of digitalis toxicity. The other levels listed are incorrect. Which drug classes are considered first-line treatment for heart failure (SELECT ALL THAT APPLY) Angiotensin-converting enzyme (ACE) inhibitors AngiotensinII receptor blcokers (ARBS) Digoxin (cardia glycoside) Beta Blockers Nesiritide (natrecor) ANS: A, B, D ACE inhibitors, ARBS, and beta blockers are now considered the first line treatments for HF Digoxin is used when the first line treatments are not successful Nesiritide is considered a last resort treatment The nurse is preparing to administer doses of hyrdrochlorothiazide and digoxin to a patient who has heart failure. The patient reports having blurred vision. The nurse notes a heart rate of 60 beats per minute and a blood pressure of 140/78 mm Hg. Which action will the nurse take? Administer the medications and request an order for serum electolytes Give both medications and evalulate serum blood glucose frequently Hold the digoxin andnotify the provider Hold the hydrochlorothiazide and notify the provider When thiazide diuretics are taken with digoxin, patients are at risk of digoxin toxicity because thiazides can cause hypokalemia. The patient has bradycardia and blurred vision, which are both signs of digoxin toxicity. The nurse should hold the digoxin and notify the provider. Serum electrolytes may be ordered, but the digoxin should not be given. The nurse is caring for a patient who is to begin reciving a thiazide diuretic to treat heart failure. When performing a health history on this pt, the nurse will be concerned about a history of which conditon? Asthma Glaucoma Gout Hypertension Thiazides block uric acid secretion, and elevated levels can contribute to gout. Patients with a history of gout should take thiazide diuretics with caution, they may need behavioral and/or pharmacologic changes to their gout treatment. A patient has begun taking spironolactone (ALDACTONE) in addition to a thiazide diuretic. With the addition of the spironolactone, the nure will counsel this patient to Continue taking a potassium supplement daily Recognizethat abdominal cramping is transient side effect Report decreased urine output to the provider Take these medications at bedtime Caution must be used when giving potassium-sparing diuretics to patients with poor renal function, so patients should be taught to report a decrease in urine output. Patients taking potassium-sparing diuretics are at risk for hyperkalemia, so they should not take potassium supplements. Abdominal cramping should be reported to the provider. The medications should be taken in the morning for patients who sleep during the night. The nurse notes a blood pressure of 160/90 mmHg in a patient taking a thiazide diuretic. The patient reports taking an herbal medicaton that a friend recommended. Which herbal product is likely, given this patients blood pressure? Ginkgo Hawthorne Licorice St. John's Wort Increased bp can result when ginkgo is used in combination with a thiazide diuretic. Hwthorne can potentiate hypotension. Licorice can incrase potassium loss, leading to hypokalemia. St. John's wort is not listed as an herbal alert substance withthiazide diuretics. A patient has been taking spironolactone to treat heart failure. The nurse will monitor for? Hyperkalemia Hypermagnesemia Hypocalcemia Hypoglycemia Spironolactone is a potassium-sparing diuretic and can cause hyperkalemia When reviewing the mechanisms of action of diuretics, the nurse knowsthat which statement is true about loop diuretics? They work by inhibiting aldosterone They are very potent, having a diuretic effect that lasts at least 6 hours They have a rapid onset of action and cause rapid diuresis They are not effective when the creatinine clearance decreaes below 25mL/min The loop diuretics have a rapid onset of action, therefore, they are useful when rapid onset is desired. Their effect lasts for about 2 hours, and a distinct advantage they have over thiazide diuretics is that their diuretic action continues even when creatinine clearance decreaes below 25mL/min. The nurse is caring for a pt who is reciving IV furosemide and morphine for the tx of acute decompensated heart failure with severe orthopnea. Which clincial finding is thebest indicator that the treatment has been effective? Weight oss of 2 lbs in 24 hours Hourly urine output greater than 60 mL Reduction in patient complaints of chest pain Reduced dyspnea with the head of bed at 30 degrees pt's major clinical manifestation of ADHF is orthopnea, the best indicator that the mes are effective is a decrease in dyspnea with the HOB at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occured, but are not as specific to evaluating this pt response During a visit to a 78 yo w/ chf, the home care nurse finds that the pt has ankle edema, a 2 kg wight gain over the past 2 days, and complains of eeling too tired to get out of bed. Based on these data finds, the best nursing d for the pt is activity intolerance related to fatigue disturbed body image related to weight gain impaired skin integrity related to ankle edema impaired gas exchange related to dyspnea on exertion The pt statement supports the dx of activity intolerance. Ther are no data to suppor the other dx, although the nurse will nee to asses for other pt problems. Which diagnositc test will be most useful to the nurse in determining whether a pt admitted with acute sob has hf? Serum troponin arterial blood gases b-type natriuretic peptide 12-lead elecrocardiogram B type peptide (BNP) is screted when ventricular pressures increase, as they do with heart failure. Elevated BNP indicates a probably or very probably dx of heart fialure. A twelvelead electrocardiogram, arterila blood gases, and troponin may also be used in determining the causes or effect of heart failure but are not as clearly dx of heart failure as BNP A pt with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5 lb weight gain in the last 3 days. The nurses priority action will be to Have the pt recall the dietary intake for the last 3 days Ask the pt about the use of the prescribed medications assess the pt for clincial manifestations of acute heart failure Teach the pt about the importance of restricting dietary sodium The 5 lb weight gain over 3 days indicates that the pts chronic heart failure may be worsening. It is important that the pt be assessed immediately for other clincial manifestations of decmpensations, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of meeication compliance may be appropriate interventions but are not the first nursing actions indicated. An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol . Which assessment finding is MOST important ofr the nurse to report to the hcp? 2+ Pedal Edema HR of 56 beats/min BP of 88/42 Complaints of fatigue pt BP indicates that the dose of metoprolo may need to be decreased bc of hypotension. Bradycardia is frequent adverse effect of b-adrenergic blockage, but the rate of 56 is NOT unusual with beta blocker.
