Question 1

The nurse is reinforcing teaching provided to a patient with Raynaud disease. Which measure should the nurse include to prevent an attack?

Accepted Answer

Raynaud disease is characterized by vasospasm of the small blood vessels, typically in the fingers and toes. Avoiding triggers that cause vasoconstriction, such as cold temperatures and stress, can help prevent attacks.

Question 2

The nurse is teaching a patient about a low-cholesterol diet. Which food choice made by the patient indicates teaching has been effective?

Accepted Answer

Oatmeal is high in soluble fiber, which can reduce the absorption of cholesterol into the bloodstream, making it a good choice for a low-cholesterol diet. Sardines, while they contain cholesterol, are also high in omega-3 fatty acids, which can improve heart health.

Question 3

The nurse is caring for a group of patients. Which patient should the nurse see first?

Accepted Answer

A patient with an aneurysm reporting sudden back pain is likely experiencing a life-threatening emergency, such as a ruptured aneurysm, which requires immediate attention.

Question 4

The nurse is contributing to the teaching plan for a patient who is taking nitroglycerin. Which action should be included if chest pain occurs?

Accepted Answer

The correct action for a patient experiencing chest pain and taking nitroglycerin is to take one tablet every 5 minutes for three doses until pain is relieved. This protocol helps to alleviate chest pain while minimizing the risk of overdose and adverse effects.

Question 5

The nurse is collecting data on a patient with varicose veins. What should the nurse document as a subjective finding of varicosities?

Accepted Answer

Subjective findings are reported by the patient, and in the case of varicose veins, a common complaint is the aching of legs. This is something the patient would express rather than something observed or measured directly by the nurse. Ankle edema, purple lesions, and palpable nodules are objective findings that can be observed or measured by the nurse.

Question 6

The nurse is teaching a patient with an abdominal aortic aneurysm about activity. Which statement made by the patient indicates an understanding of the teaching?

Accepted Answer

Walking for 20 minutes every other day is a low-impact activity that is generally safe for someone with an abdominal aortic aneurysm, as it does not significantly increase blood pressure or strain on the aorta.

Question 7

A patient with peripheral venous disease (PVD) is sitting in a chair and has edematous and purple feet. What action should the nurse to take?

Accepted Answer

Elevating the legs can help reduce edema and improve venous return in patients with peripheral venous disease.

Question 8

The nurse is reinforcing teaching a patient about resuming sexual activity following an MI 3 days ago. Which statement indicates patient understanding?

Accepted Answer

The ability to climb two flights of stairs without experiencing symptoms such as chest pain, shortness of breath, or excessive fatigue is often used as a guideline to assess a patient's physical readiness to resume sexual activity after a myocardial infarction (MI). This guideline is based on the idea that if a person can perform this level of physical activity without symptoms, they likely have the cardiovascular fitness to engage in sexual activity, which has a similar level of exertion.

Question 9

A patient being treated for an acute MI reports severe chest pressure, "as if someone is standing on my chest." What should the nurse do first?

Accepted Answer

Obtaining vital signs is the first step in assessing the patient's condition and determining the severity of the situation. It provides essential information about the patient's hemodynamic status and helps guide further interventions.

Question 10

The nurse is teaching a patient with venous stasis ulcers. Which information should the nurse include in the teaching?

Accepted Answer

Compression stockings help to improve venous return and reduce edema, which can help to heal venous stasis ulcers.

Question 11

The nurse is caring for a patient who underwent vascular surgery. During a neurovascular check, the nurse notes the extremity is cool to touch and dusky. Which action should the nurse take?

Accepted Answer

Notifying the healthcare provider (HCP) is crucial when changes in the neurovascular status of a postoperative patient are observed, such as coolness and duskiness of the extremity, which may indicate compromised blood flow or other complications.

Question 12

The nurse is assessing a patient who is receiving rosuvastatin (Crestor) to reduce cholesterol. Which finding should concern the nurse?

Accepted Answer

Muscle pain is a potential side effect of statins like rosuvastatin (Crestor) and can be an indication of a serious condition called rhabdomyolysis, especially if severe. This condition involves the breakdown of muscle tissue leading to kidney damage.

Question 13

The nurse is assessing a patient with an aneurysm. Which finding should be reported to the RN immediately?

Accepted Answer

Sudden flank pain can indicate a rupture or impending rupture of an aneurysm, which is a medical emergency requiring immediate attention.

Question 14

The nurse is teaching a class about coronary artery disease and explains atherosclerosis. Which statement made by the patient indicates an understanding of the teaching?

Accepted Answer

Atherosclerosis involves the buildup of plaque in the arteries, which can lead to coronary artery disease.

Question 15

A patient who develops chest pain says the pain is a 9 on a scale of 0 to 10. Which action should the nurse take?

Accepted Answer

The nurse should notify the registered nurse (RN) because chest pain rated as 9 out of 10 is severe and requires immediate assessment and intervention by a higher-level healthcare provider.

Question 16

The nurse is reinforcing teaching provided to a patient with an aneurysm. Which patient statement indicates correct understanding of a dissecting aneurysm?

Accepted Answer

A dissecting aneurysm occurs when there is a tear in the inner layer of the arterial wall, allowing blood to split the layers apart. This is different from an outpouching (saccular aneurysm), a communication between an artery and a vein (arteriovenous fistula), or an enlargement of the entire circumference of the artery (fusiform aneurysm).

Question 17

The nurse is caring for a patient with lymphangitis. Which interventions should the nurse implement first?

Accepted Answer

Administering analgesics as prescribed addresses the patient's immediate pain and discomfort, which is a priority in managing symptoms.

Question 18

The nurse is assessing a patient with a myocardial infarction who may receive tissue plasminogen activator [t-PA]. Which question is most important for the nurse to ask?

Accepted Answer

The most important question to ask is "What time did the chest pain begin?" because tissue plasminogen activator (t-PA) is most effective when given within a specific time frame after the onset of myocardial infarction symptoms, typically within 3 to 4.5 hours. This information directly impacts the treatment plan and the use of t-PA.

Question 19

The nurse is reviewing laboratory values for a patient with chest pain. Which requires notification of the healthcare provider?

Accepted Answer

Troponin levels above the 99th percentile upper reference limit are indicative of myocardial injury, commonly seen in myocardial infarction. A level of 0.70 ng/mL is elevated and requires immediate notification of the healthcare provider, as it suggests cardiac injury.

Question 20

The nurse is caring for a group of patients. Which patient is at highest risk for having a myocardial infarction (MI) at a young age?

Accepted Answer

D) A 23-year-old female who smokes and uses oral contraceptives is at the highest risk for having a myocardial infarction (MI) at a young age. Smoking significantly increases the risk of cardiovascular diseases, and the use of oral contraceptives can further elevate this risk, especially in smokers.

Quiz 24: Nursing Care of Patients With Occlusive Cardiovascular Disorders